Tendon healing follows a complex series of coordinated events, which ultimately produces a mechanically inferior tissue more scar‐like than native tendon. More regenerative healing occurs when ...anti‐inflammatory M2 macrophages play a more dominant role. Mesenchymal stromal/stem cells (MSCs) are able to polarize macrophages to an M2 immunophenotype via paracrine mechanisms. We previously reported that coculture of CD14+ macrophages (MQs) with MSCs resulted in a unique M2‐like macrophage. More recently, we generated M2‐like macrophages using only extracellular vesicles (EVs) isolated from MSCs creating “EV‐educated macrophages” (also called exosome‐educated macrophages EEMs), thereby foregoing direct use of MSCs. For the current study, we hypothesized that cell therapy with EEMs would improve in vivo tendon healing by modulating tissue inflammation and endogenous macrophage immunophenotypes. We evaluated effects of EEMs using a mouse Achilles tendon rupture model and compared results to normal tendon healing (without any biologic intervention), MSCs, MQs, or EVs. We found that exogenous administration of EEMs directly into the wound promoted a healing response that was significantly more functional and more regenerative. Injured tendons treated with exogenous EEMs exhibited (a) improved mechanical properties, (b) reduced inflammation, and (c) earlier angiogenesis. Treatment with MSC‐derived EVs alone were less effective functionally but stimulated a biological response as evidenced by an increased number of endothelial cells and decreased M1/M2 ratio. Because of their regenerative and immunomodulatory effects, EEM treament could provide a novel strategy to promote wound healing in this and various other musculoskeletal injuries or pathologies where inflammation and inadequate healing is problematic. Stem Cells 2019;37:652–662
Extracellular vesicles (EVs) were isolated from bone marrow derived mesenchymal stem/stromal cells (BMMSCs) via ultracentrifugation. CD14+ monocytes were obtained from peripheral blood, cultured, activated to CD14+ macrophages, and educated with MSC‐derived EVs, producing EV‐educated macrophages (EEMs). Treatment with EEMs using a mouse Achilles tendon injury model accelerated healing as indicated by reduced inflammation, early angiogenesis, and improved strength and modulus.
Purpose
Studies have shown that elongation of the injured Achilles tendon after acute Achilles tendon rupture (ATR) is negatively associated with clinical outcomes. The difference between operative ...and non-operative treatment on the length of the Achilles tendon is only sparsely investigated. The aim of the study was to investigate if the operative and non-operative treatment of ATR had different effects on tendon elongation.
Methods
The study was performed as a registry study in the Danish Achilles tendon database (DADB). The primary outcome of the study was an indirect measure of Achilles tendon length: the Achilles tendon resting angle (ATRA) at 1-year follow-up. The variable of interest was treatment (operative or non-operative).
Results
From August 2015 to January 2019, 438 patients (154 operatively treated and 284 non-operatively treated) were registered with full baseline data and had their ATRA correctly registered at 1-year follow-up in DADB. The analysis did not show a clinically relevant nor statistically significant difference in ATRA between operative and non-operatively treated patients at 1-year follow-up (mean difference − 1.2°; 95% CI − 2.5; 0.1; n.s) after adjustment for potential confounders.
Conclusion
There were neither clinically relevant nor statistically significant differences in terms of the ATRA at 1-year follow-up between the operative and non-operatively treated patients. This finding suggests that operative treatment does not lead to a clinically relevant reduction in tendon elongation compared to non-operative treatment and it should therefore not be used as an argument in the choice of treatment.
Level of evidence
Level III.
Introduction
Until now, a treatment protocol for Achilles tendon re-rupture (ATRR) occurring in the postoperative period 5–12 weeks following primary Achilles tendon repair has not been established. ...We refer to this time frame as the subacute postoperative phase, and the objective of this study was to assess the efficacy of conservative treatment for subacute ATRR in this phase.
Materials and methods
We conducted a retrospective review of 390 cases (385 patients) who had undergone primary Achilles tendon repair using the 4-strand Krachow method between January 2010 and August 2021. All patients were subjected to more than 12 months of follow-up and were categorized into two groups based on the presence of subacute ATRR: Group 1 comprised 370 cases without ATRR, while Group 2 comprised 20 cases with ATRR. Following confirmation of ATRR, we immediately applied a below-knee cast in an ankle plantar flexed position (25°–30°), followed by bracing according to the same rehabilitation plan used for the primary repair. After administering conservative treatment to the patients with ATRR, we compared several outcome parameters between the two groups, including isokinetic plantar flexion power measured using a dynamometer, time required for a single heel raise (t-SHR), time needed for ten repetitive SHRs (t-SHR10), Achilles Tendon Total Rupture Score (ATRS), and Foot and Ankle Ability Measure (FAAM) scores. The baseline timepoints for Groups 1 and 2 were the dates of the primary repair and the re-injury event.
Results
After primary Achilles tendon repair, subacute ATRR occurred in 5.1% of patients. There were no significant differences between the groups in terms of t-SHR and t-SHR10 (P = 0.281, 0.486). Similarly, the isokinetic dynamometer measurements revealed no significant differences in peak torque for plantar flexion at angular velocities of 30°/s and 120°/s, both in absolute values and as a percentage of the contralateral side, between the groups (P > 0.05 for each). However, ATRSs were significantly lower in Group 2 compared to Group 1 before 6 months (P < 0.05), as were FAAM-Activities of Daily Living scores at 6 months (P < 0.05). After 12 months, there were no significant differences in these scores between the two groups (both P > 0.05).
Conclusion
Conservative treatment for subacute ATRR following primary Achilles tendon repair yields clinical outcomes comparable to those without ATRR. Therefore, we recommend that surgeons consider relying on the patient’s natural healing capabilities rather than opting for aggressive surgical interventions, as expediting such operations may be unnecessary for subacute injuries.
Background:
Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated ...endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR.
Methods:
Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated.
Results:
All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength.
Conclusion:
The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort.
Level of Evidence:
Level II, prospective cohort case series study.
Abstract Acute ruptures of the Achilles tendon are a common injury, and debate has continued in published studies on how best to treat these injuries. Specifically, controversy exists regarding the ...surgical approaches for Achilles tendon repair when one considers percutaneous versus open repair. The present study investigated the biomechanical strength of 3 different techniques for Achilles tendon repair in a cadaveric model. A total of 36 specimens were divided into 3 groups, each of which received a different construct. The first group received a traditional Krackow suture repair, the second group was repaired using a jig-assisted percutaneous suture, and the third group received a repair using a jig-assisted percutaneous repair modified with suture anchors placed into the calcaneus. The specimens were tested with cyclical loading and to ultimate failure. Cyclical loading showed a trend toward a stronger repair with the use of suture anchors after 10 cycles ( p = .295), 500 cycles ( p = .120), and 1000 cycles ( p = .040). The ultimate load to failure was greatest in the group repaired with the modified knotless technique using the suture anchors ( p = .098). The results of the present study show a clear trend toward a stronger construct in Achilles repair using a knotless suture anchor technique, which might translate to a faster return to activity and be more resistant to an early and aggressive rehabilitation protocol. Further clinical studies are warranted to evaluate this technique in a patient population.
Background
Achilles tendinopathy is a common overuse injury, especially among athletes involved in activities that include running and jumping. Often an initial period of rest from the pain-provoking ...activity is recommended.
Purpose
To prospectively evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome.
Study Design
Randomized clinical control trial; Level of evidence, 1.
Methods
Thirty-eight patients with Achilles tendinopathy were randomly allocated to 2 different treatment groups. The exercise training group (n = 19) was allowed, with the use of a pain-monitoring model, to continue Achilles tendon-loading activity, such as running and jumping, whereas the active rest group (n = 19) had to stop such activities during the first 6 weeks. All patients were rehabilitated according to an identical rehabilitation program. The primary outcome measures were the Swedish version of the Victorian Institute of Sports Assessment—Achilles questionnaire (VISA-A-S) and the pain level during tendon-loading activity.
Results
No significant differences in the rate of improvements were found between the groups. Both groups showed, however, significant (P < .01) improvements, compared with baseline, on the primary outcome measure at all the evaluations. The exercise training group had a mean (standard deviation) VISA-A-S score of 57 (15.8) at baseline and 85 (12.7) at the 12-month follow-up (P < .01). The active rest group had a mean (standard deviation) VISA-A-S score of 57 (15.7) at baseline and 91 (8.2) at the 12-month follow-up (P < .01).
Conclusions
No negative effects could be demonstrated from continuing Achilles tendon-loading activity, such as running and jumping, with the use of a pain-monitoring model, during treatment. Our treatment protocol for patients with Achilles tendinopathy, which gradually increases the load on the Achilles tendon and calf muscle, demonstrated significant improvements. A training regimen of continued, pain-monitored, tendon-loading physical activity might therefore represent a valuable option for patients with Achilles tendinopathy.
Achilles tendon ruptures are common injuries that often lead to long-term functional deficits. Despite the prevalence of these injuries, the mechanism responsible for limited function has not yet ...been established. Therefore, the purpose of this study was to present preliminary findings that support a hypothesis that skeletal muscle remodeling is the driving factor of poor outcomes in some patients. Biomechanical and ultrasonography assessments were performed on a patient that presented with poor functional outcomes 2.5 years after a surgically-repaired acute Achilles tendon rupture. Single-leg heel raise height was decreased by 75% in the affected limb (3.0 cm compared to 11.9 cm) while walking mechanics showed no deficits. Ultrasonography revealed that the affected medial gastrocnemius muscle was less thick and had shorter, more pennate fascicles compared to the unaffected limb. A simple computational model of a maximal-effort plantarflexion contraction was employed to test the implications of changes in muscle architecture on single-leg heel raise function. Subject-specific measurements of fascicle length and pennation were input into the model, which supported these architectural parameters as being drivers of heel raise function. These preliminary findings support the hypothesis that an Achilles tendon rupture elicits changes in skeletal muscle architecture, which reduces the amount of work and power the joint can generate. This multidisciplinary framework of biomechanical, imaging, and computational modeling provides a unique platform for studying the complex interactions between structure and function in patients recovering from Achilles tendon injuries.
Background:
Following Achilles tendon rupture, tendon elongation leads to long term deficits in calf function. A surrogate measure of Achilles tendon length, Achilles tendon resting angle (ATRA), has ...been described but has not been validated against length measured using ultrasound. Therefore, the purpose of this study was to validate the ATRA against ultrasound. Secondarily, this study aimed to identify the relationship of other factors (tendon mechanical properties, heel-rise test performance) to the ATRA.
Methods:
Individuals following unilateral Achilles tendon rupture were included. ATRA was measured in knee flexed and extended positions. Tendon elongation was measured using extended field of view ultrasound imaging. Continuous shear wave elastography quantified tendon mechanical properties. The relationship between variables was tested using Spearman’s ρ. Subgroup analysis was used to compare subjects with less then or greater than 1 year following rupture. A total of 42 participants (with a mean of 18.2 months following rupture SD = 35.9) were included.
Results:
Tendon elongation related with relative ATRA with knee flexed (ρ = .491, P = .001) and knee extended (ρ = 0.501, P = .001) positions. In individuals greater than 1 year following rupture, relative ATRA with the knee flexed related to shear modulus (ρ = .800, P = .01) and total work on the heel-rise test (ρ = –.782, P = .008) relative to the uninjured side.
Conclusion:
Relative ATRA in both knee flexed and knee extended positions has a moderate relationship to tendon elongation within the first year following rupture. After 1 year, the relative ATRA with knee flexed may be a better indicator of tendon elongation and also related to tendon mechanical properties and heel-rise test performance.
Level of Evidence:
Level III, case-control study.
Achilles insertional tendinopathy (AIT) is a common injury and its pathogenesis is still not entirely clear. It manifests with worsening pain and functional limitations. When conservative treatment ...fails, surgical treatment is indicated. The purpose of our research is to evaluate the outcome after one year in patients affected by AIT (calcific and non-calcific AIT) who were treated at our centre.
Between 2014 and 2021, 42 patients suffering from AIT - a total of 47 feet - underwent surgery at our centre. The patients filled in the VISA-A and AOFAS questionnaires at the pre-operative consultation and at the clinical check-up after one year of follow up.
Of the 47 feet treated, 28 were calcific AITs treated by medial access and tendon reinsertion using a knotless double suture anchor system (Achilles Suture Bridge™) and 19 were non-calcific tendinopathies treated using a lateral paratendinous approach. The one-year clinical results show an increase in VISA-A scores of 48.6 and AOFAS scores of 44.1 and the absence of complications. Only one patient reported a recurrence of certain symptoms and none of the patients were hospitalized for recurrence.
The literature is unable to establish a gold standard of treatment for AIT. The method we have used has shown excellent short- and medium-term results without any complications. Further studies are needed to prove its effectiveness in the long term.
Background:
Whether an Achilles tendon rupture is treated surgically or not, complications such as muscle weakness, decrease in heel-rise height, and gait abnormalities persist after injury.
Purpose:
...The purpose of this study was to evaluate if side-to-side differences in maximal heel-rise height can be explained by differences in Achilles tendon length.
Study Design:
Case series; Level of evidence, 4.
Method:
Eight patients (mean SD age of 46 13 years) with acute Achilles tendon rupture and 10 healthy subjects (mean SD age of 28 8 years) were included in the study. Heel-rise height, Achilles tendon length, and patient-reported outcome were measured 3, 6, and 12 months after injury. Achilles tendon length was evaluated using motion analysis and ultrasound imaging.
Results:
The Achilles tendon length test-retest reliability (intraclass correlation coefficient = 0.97) was excellent. For the healthy subjects, there were no side-to-side differences in tendon length and heel-rise height. Patients with Achilles tendon ruptures had significant differences between the injured and uninjured side for both tendon length (mean SD difference, 2.6-3.1 1.2-1.4 cm, P = .017-.028) and heel-rise height (mean SD difference, –4.1 to –6.1 1.7-1.8 cm, P = .012-.028). There were significant negative correlations (r = −0.943, P = .002, and r = −0.738, P = .037) between the side-to-side difference in heel-rise height and Achilles tendon length at the 6- and 12-month evaluations, respectively.
Conclusion:
The side-to-side difference found in maximal heel-rise height can be explained by a difference in Achilles tendon length in patients recovering from an Achilles tendon rupture. Minimizing tendon elongation appears to be an important treatment goal when aiming for full return of function.
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