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Early, controlled tension improves the material properties of healing human Achilles tendons after rupture: a randomized trial
Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics.
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Orthopaedic Centre, Department of Orthopaedics Linköping.
2013 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Weight-bearing in a fixed brace after acute Achilles tendon rupture does not necessarily lead to mechanical tension in the tendon. Early motion has a positive effect on the clinical outcome, but it is not clear if this is due to effects on tendon strength or to unspecific effects. The aim of this study was to examine if tensional loading leads to improvement of the mechanical properties of the healing, human Achilles tendon.

Hypothesis: The elastic modulus of the tendon callus is increased by early tensional loading.

Study Design: Randomized controlled trial; level of evidence: 2.

Methods: Thirty-five patients with an acute Achilles tendon rupture were recruited consecutively. They were operated with a single suture, and received metal markers in the distal and proximal part of the tendon. After surgery, patients were randomized to either cast immobilization for 7 weeks or tensional loading. The latter group wore a cast for 2 weeks, and then a removable foam walker boot for 5 weeks. They were instructed to remove the boot twice daily and push a special training pedal to produce a predetermined, gradually increasing tensional load on the healing tendon. At 7, 19 and 52 weeks postoperatively, patients were investigated with Roentgen Stereophotogrammetric Analysis (RSA) under different loading conditions, and computed tomography (CT). The collected data allowed calculation of modulus of elasticity. At 52 weeks, we also examined clinical outcome, using the Achilles tendon Total Rupture Score (ATRS) and a heel-raise index.

Results: The elastic modulus at 19 and 52 weeks was higher in the tensional loading group. There was no significant difference in ATRS or heel-raise index at 52 weeks. As in previous studies, there was a significant correlation between the modulus at 7 weeks and the heel-raise index at 52 weeks. There was moderate tendon elongation.

Conclusion: Early tensional loading improves the mechanical properties of the healing Achilles tendon.

Place, publisher, year, edition, pages
2013.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-91728OAI: oai:DiVA.org:liu-91728DiVA: diva2:618913
Available from: 2013-04-30 Created: 2013-04-30 Last updated: 2013-04-30Bibliographically approved
In thesis
1. Stiffness of the healing human Achilles tendon
Open this publication in new window or tab >>Stiffness of the healing human Achilles tendon
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Achilles tendon ruptures in humans are followed by a long period of immobilisation, rehabilitation and limitations of physical activity and sometimes work also. This prolonged period probably leaves a marginal for improvement in the management of this injury. Animal studies have shown that there are several possibilities to influence and improve tendon healing.

The aim of this thesis was to find a way to examine the mechanical properties of the healing human Achilles tendon and, by using that method, to gain a better understanding of the tissue properties and healing process in these tendons. It was also our aim to use our knowledge from animal studies in an attempt to improve tendon healing in humans.

We developed a radiological method using radiostereophotogrammetric analysis (RSA) and computed tomography (CT), which enabled us to measure the stiffness of the healing Achilles tendon. The results of these measurements, as early as 7 weeks after injury correlated with the late clinical results in all studies. Clinical results were measured using a heel-raise test comparing the injured with the non-injured tendon. We could not find a significant difference in stiffness between patients treated surgically or non-surgically. Neither could we demonstrate that platelet-rich plasma improved the mechanical properties of the healing tendon or the clinical outcome, within the limits of the statistical power. In contrast, patients following a specific training programme with early tension loading of the tendon twice a day developed stiffer tendon tissue later in the healing process.

Since RSA is unsuitable for routine clinical use, we evaluated the possibility to use radiodensity findings from CT as a proxy for healing and its correlation to mechanical and clinical results. Density and mechanical properties correlated strongly when analysing all time points together, but only weakly at each particular point in time. Density may still be useful in describing mechanical properties at a later stage of repair, but this remains to be seen.

In conclusion, these studies show that early mechanical properties correlate to late clinical outcome and that the early use of daily tension loading sessions leads to an improvement in the mechanical properties of the tendon tissue.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. 59 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1356
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-91727 (URN)978-91-7519-674-9 (ISBN)
Public defence
2013-06-04, Elsa Brändströmsalen, Hälsouniversitetet, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2013-04-30 Created: 2013-04-30 Last updated: 2013-05-13Bibliographically approved

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Schepull, ThorstenAspenberg, Per

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