Acute achilles tendon rupture : predictors and intervention to promote outcome

Background: Orthopaedic trauma and surgery is still associated with major complications related to immobilization, which results in reduced circulation, thromboembolic events, impaired healing and functional deficits. An acute Achilles tendon rupture (ATR) is associated with a high risk of deep venous thrombosis (DVT) and varied extent of impaired physical ability. The knowledge of underlying factors leading to hampered functional outcome one year after surgery of ATR is still limited. Since pharmacological DVTprophylaxis has low or no effect during lower leg immobilization it is speculated whether adjuvant mechanical treatment with intermittent pneumatic compression (IPC) applied during lower limb immobilization can reduce the incidence of DVT. Aims: The purpose of this thesis was to assess predictors of outcome after acute ATR and to investigate if an intervention using IPC could reduce the risk of immobilization-induced complications, i.e. to reduce DVT-incidence and to enhance the healing response. Results and Discussion: In a prospective cohort of ATR patients using combined patient reported- and functional outcome measures predictors of outcome were investigated. This thesis established that three independent factors predict patient outcome at one year postoperatively. Thus, it was demonstrated that postoperative DVT during leg immobilization, aging and male gender are independent predictive factors of patient outcome. Moreover, more than half of the patients exhibited significant functional deficits at one year postoperatively. These results imply that specific interventions are warranted to prevent DVT. In a prospective randomized study, intervention with IPC under plaster cast was compared to treatment-as-usual with plaster cast only. DVT incidence was assessed using compression duplex ultrasound (CDU), by two ultrasonographers blinded to the treatment. The study ended prematurely since an interim analysis demonstrated a high, non-significant incidence of DVT in both groups, IPC (75%) and controls (50%), and a malfunctioning of the IPC device under plaster cast. These findings suggest that other means of applying IPC during immobilization should be evaluated. The above conclusions resulted in a prospective randomized trial comparing adjuvant IPC applied under an orthosis versus plaster cast only. CDU analysis demonstrated significantly reduced incidence of DVT at 2 weeks post-operatively, 21% in the IPC-group compared to 37% in the control group. Patients aged ≥ 40 years exhibited an almost fivefold increased odds of DVT. Moreover, patients that received no IPC treatment exhibited an almost threefold increased odds for DVT, independently of age. Furthermore, using microdialysis technique, adjuvant IPC treatment was shown to increase the metabolic activity at 2 weeks post-operative ATR. The demonstration that adjuvant IPC effectively reduced DVT incidence, and also is capable of enhancing the metabolic response suggests that IPC treatment may not only be a viable means of prophylaxis against DVT in an outpatient setting, but possibly also a method of promoting healing. Conclusions: This thesis established that poor outcome is common after ATR and that three specific, independent risk factors can predict a negative outcome after ATR. One of these risk factors, i.e. DVT, can be prevented by IPC used under an orthosis during lower limb immobilization. The results suggest that all patients with lower leg immobilization should be screened for risk factors of DVT and that IPC may be an effective, non-pharmacological outpatient approach to reduce the risk of DVT, maybe also for enhancement of healing

Ageing, deep vein thrombosis and male gender predict poor outcome after acute Achilles tendon rupture

Background: Patients with acute Achilles tendon rupture (ATR) exhibit prolonged healing, high incidence of deep venous thrombosis (DVT) and a wide variation of functional outcome. This extensive discrepancy in outcome may be explained by a lack of knowledge of detrimental factors, and subsequent shortage of adequate interventions. Methods: A total of 111 patients (84 men, 16 women; mean age 40.3±8.4) with acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Candidate predictors of ACOS included; treatment, sex, age, smoking, body mass index (BMI), time to surgery, physical activity level pre- and post-injury, symptoms, quality of life and DVT-incidence. Results: Three independent variables correlated significantly with the dichotomized outcome score ACOS, while the other factors demonstrated no correlation. Low age (40 or less=0; above 40=1) was the strongest independent predictor of developing a good outcome at one year after ATR (OR= 0.20, 95 % C.I. 0.08 – 0.51), followed by female gender (Man= 1; Woman= 2) (OR= 4.18, 95 % C.I. 1.01 – 17.24). Notably, patients without a DVT (No=0, Yes=1) during post-operative immobilization experienced a better outcome (OR= 0.31, 95 % C.I. 0.12 – 0.80). Conclusion: DVT during leg immobilization, aging and male gender are independent negative predictors of outcome in patients with acute ATR. Age and gender should be further studied as to pinpoint the underlying causes leading to poor outcome. To enhance the outcome after ATR the first clinical focus should be on DVT-prevention during immobilization, possibly by usage of mechanical compression therapy and early weight bearing and mobilization.The Swedish Research CouncilDJOStockholm County Council and Karolinska InstitutetSwedish National Centre for Sports ResearchAccepte

Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery

To perform a meta-analysis investigating venous thromboembolism (VTE) following isolated foot and ankle surgery and propose guidelines for VTE prevention in this group of patients. Following a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence. 43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6% (95% CI 0.4-0.8%) and 1% (95% CI 0.2-1.7%), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5% (95% CI 6.8-18.2%) and 10.5% (95% CI 5.0-15.9%), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria. The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7% (95% CI 5.5-8.5%) and radiological incidence of 35.3% (95% CI 26.4-44.3%). Isolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually. I

STOP leg clots - Swedish multicentre trial of outpatient prevention of leg clots : study protocol for a randomised controlled trial on the efficacy of intermittent pneumatic compression on venous thromboembolism in lower leg immobilised patients

Introduction Leg immobilisation in a cast or an orthosis after lower limb injuries is associated with a high risk of complications of venous thromboembolism (VTE) and hampered healing. Current pharmacoprophylaxes of VTE are inefficient and associated with adverse events. Intermittent pneumatic compression (IPC) could represent a novel, efficient and safe VTE-prophylactic alternative that may enhance injury healing. The aim of STOP leg clots is to assess the efficacy of adjuvant IPC-therapy on reduction of VTE incidence and improvement of healing in lower leg immobilised outpatients. Methods and analysis STOP leg clots is a multicentre randomised controlled superiority trial. Eligible patients (700 patients/arm) with either an acute ankle fracture or Achilles tendon rupture will be randomised to either addition of IPC during lower-leg immobilisation or to treatment-as-usual. The primary outcome will be the total VTE incidence, that is, symptomatic and asymptomatic deep venous thrombosis (DVT) or symptomatic pulmonary embolism (PE), during the leg immobilisation period, approximately 6-8 weeks. DVT incidence will be assessed by screening whole leg compression duplex ultrasound at removal of leg immobilisation and/or clinically diagnosed within the time of immobilisation. Symptomatic PE will be verified by CT. Secondary outcomes will include patient-reported outcome using validated questionnaires, healing evaluated by measurements of tendon callus production and changes in VTE-prophylactic mechanisms assessed by blood flow and fibrinolysis. Data analyses will be blinded and based on the intention-to-treat. Ethics and dissemination Ethical approval was obtained by the ethical review board in Stockholm, Sweden, Dnr 2016/1573-31. The study will be conducted in accordance with the Helsinki declaration. The results of the study will be disseminated in peer-reviewed international journals.Funding Agencies|Swedish research councilSwedish Research CouncilEuropean Commission [Dnr: 2017-00202]</p

Deep learning classification of shoulder fractures on plain radiographs of the humerus, scapula and clavicle

In this study, we present a deep learning model for fracture classification on shoulder radiographs using a convolutional neural network (CNN). The primary aim was to evaluate the classification performance of the CNN for proximal humeral fractures (PHF) based on the AO/OTA classification system. Secondary objectives included evaluating the model’s performance for diaphyseal humerus, clavicle, and scapula fractures. The training dataset consisted of 6,172 examinations, including 2–7 radiographs per examination. The overall area under the curve (AUC) for fracture classification was 0.89, indicating good performance. For PHF classification, 12 out of 16 classes achieved an AUC of 0.90 or greater. Additionally, the CNN model had excellent overall AUC for diaphyseal humerus fractures (0.97), clavicle fractures (0.96), and good AUC for scapula fractures (0.87). Despite the limitations of the study, such as the reliance on ground truth labels provided by students with limited radiographic assessment experience, our findings are in concordance with previous studies, further consolidating CNN as potent fracture classifiers in plain radiographs. The inclusion of multiple radiographs with different views from each examination, as well as the generally unselected nature of the sample, contributed to the overall generalizability of the study. This is the fifth study published by our group on AI in orthopaedic radiographs, which has consistently shown promising results. The next challenge for the orthopaedic research community will be to transfer these results from the research setting into clinical practice. External validation of the CNN model should be conducted in the future before it is considered for use in a clinical setting