eine Analyse der Achillessehnennaht mit dem Dresdener Instrument

Die Achillessehnenruptur ist eine der häufigsten Sehnenrupturen des Menschen, deren Inzidenz nicht nur durch die wachsende Bedeutung des Freizeitsports in den letzten Jahrzehnten deutlich gestiegen ist (60,61). Trotz gestiegenem wissenschaftlichen Interesse gibt es noch immer keinen international gültigen Konsens für eine Therapie, die einerseits sicher Komplikationen vermeidet und andererseits zuverlässig die Funktion des Triceps surae wiederherstellt. Minimal-invasive Techniken, wie beispielsweise die minimal-invasive Achillessehnennaht mit dem Dresdener Instrument haben mit einer kumulierten Komplikationsrate von 2-5 % studienübergreifend (55,119,120,134) die geringste Komplikationsrate an operativen (Infektion, Nervenläsion) wie nicht-operativen (Re-Ruptur) Komplikationen. Trotz niedriger Komplikationsrate offenbarten sich in den durchgeführten Studien auch nach minimal-invasiver Achillessehnennaht mit dem Dresdener Instrument funktionelle Defizite. Knapp ein Viertel der freizeitsportorientierten Patienten konnte nicht mehr an ihr vorheriges Leistungsniveau anknüpfen. Im Seitenvergleich ließen sich strukturelle wie auch biomecha-nische Veränderungen der Muskel-Sehnen-Einheit detektieren. Strukturelle Veränderungen, wie eine vermehrte Muskelatrophie äußerten sich durch signifikant geringere Score-Ergebnisse, während eine Achillessehnenverlängerung vorrangig mit einer signifikant alterierten Sprunggelenkskinematik beim Gang in der Ebene und auf der Treppe assoziiert war (135). Abgesehen von diesen strukturellen Veränderungen der Muskel-Sehnen-Einheit konnten selbst im mittel- bis langfristigen Verlauf nach Achillessehnennaht noch verminderte bio-mechanische Sehnenqualitäten in Form einer signifikant verringerten Dehnbarkeit, bzw. sig-nifikant erhöhten Steifigkeit nachgewiesen werden. Insbesondere die vermehrte Sehnensteifigkeit korrelierte mit abnehmenden plantaren Bodenreaktionskräfte (136). Es überrascht daher nicht, dass die strukturelle wie auch biomechanische „Narbe“ des Triceps surae maßgeblichen Einfluss auf dessen Funktion bei der Erfüllung seiner statischen und dynamischen Aufgaben nimmt. Die Frage, die sich hieran anschließt, ist, in wie weit die Sehnenheilung extrinsisch so moduliert werden kann, dass die Muskel-Sehnen-Einheit seine ursprüngliche Funktion vollständig wiedererlangt. Eine adäquate Nachbehandlung spielt hierbei elementare Rolle. Vielfach wurde in den vergangenen zwei Jahrzehnten der Stellenwert der früh-funktionellen Mobilisation nach Achil-lessehnenruptur hervorgehoben. Über den Mechanismus der Mechanotransduktion, der durch den mechanischen Reiz der früh-funktionellen Mobilisation initiiert wird, kommt es im Gegensatz zur immobilisierenden Nachbehandlung zu Ausbildung eines histologisch reiferen Sehnengewebes, welches dem strukturellen Aufbau von nativem Gewebe näher kommt. In einer Pilotstudie wurde daher der Einfluss der Vollbelastung mit frühzeitigem Beginn der Krankengymnastik im Vergleich zur herkömmlichen Mobilisation mit Teilbelastung auf die biomechanischen Sehnenqualitäten in der Frühphase der postoperativen Rehabilitation untersucht (137). Entgegen der Annahme konnte allerdings weder eine signifikante Verbesserung der Sehneneigenschaften noch zu eine schnellere Rehabilitation festgestellt werden. Es konnte aber auch gezeigt werden, dass eine frühe Vollbelastung nicht mit einer signifikanten Achillessehnenverlängerung vergesellschaftet ist und somit auch für die postoperative Mobi-lisation nach minimal-invasiver Naht zulässig ist (137). Neben einem früh-funktionellen Nachbehandlungskonzept mögen weitere Faktoren das Er-gebnis positiv beeinflussen. So zeigte es sich in der retrospektiven Untersuchung (134), dass diejenigen Patienten, die innerhalb der ersten 48 Stunden operiert worden waren, ein signifikant schlechteres Ergebnis in den PROMs erreichten sowie ihr eigenes Abschneiden subjek-tiv schlechter einschätzen, als die Patienten, die im Intervall 2. - 10. Tag nach Achillessehnenruptur sich einer Operation unterzogen hatten. Vor dem Hintergrund, dass die Sehnenheilung phasenweise abläuft, ist es also denkbar, dass eine zu unterschiedlichen Zeitpunkten stattfindende Operation auf ein unterschiedliches Expressionsmuster von Matrixproteinen, wie MMPs oder TIMPs trifft. In der Tat, zeigten sich je nach Rupturalter im Vergleich zu gesundem Sehnengewebe ganz unterschiedliche Expressionsmuster an Matrixproteinen und Kollagenen. Mit zunehmend späteren OP-Zeitpunkten fand sich ein Kollagenabbau wie auch eine fortgeschrittene Sehnendegeneration, die möglicherweise mit der zunehmenden proteolytischen Aktivität einzelner MMPs zusammenhängen könnten. Da zum gegenwärtigen Zeitpunkt die physiologische oder auch pathophysiologische Rolle der einzelnen MMPs und TIMPs noch unklar ist, sind weitere Studien gefordert, die molekularbiologischen Prozesse der Sehnenheilung zu entschlüsseln, um ein tieferes Verständnis dieses komplexen Vorganges zu bekommen. Nichtsdestotrotz muss neben der Grundlagenforschung auch die klinische Datenlage ver-bessert und strukturiert werden, denn bei der Suche nach der optimalen Therapieform der Achillessehnenruptur kommt sicherlich die heterogene Studienlage erschwerend hinzu. Das Editorial Board der Fachzeitschrift Foot and Ankle International hat aus ähnlichen Beweg-gründen versucht, die Publikationsflut der Artikel über Sprunggelenkprothetik zu reglementieren, indem es klare Eingangsparameter definiert hat, die für eine Publikation in dem Journal zwingend erforderlich sind (192). Neben einer Verbesserung der Studienqualität erhoffte man sich so auch eine verbesserte Vergleichbarkeit der Studien untereinander. Eine ähnliche Situation trifft auch auf die immense Studienlage der Achillessehnenruptur zu

Muscle Fascicles Exhibit Limited Passive Elongation Throughout the Rehabilitation of Achilles Tendon Rupture After Percutaneous Repair

Achilles tendon rupture (ATR) results in long-term functional and structural deficits, characterized by reduced ankle mobility and plantarflexor muscle atrophy. However, it remains unclear how such functional impairments develop after surgical repair. While it is known that this injury negatively affects the tendon's function, to date, limited work has focused on the short-term effect of ATR on the structure of the muscles in series. The aim of this study was to characterize changes in medial gastrocnemius architecture and its response to passive lengthening during the post-surgical rehabilitative period following ATR. Both injured and contralateral limbs from 10 subjects (1 female, BMI: 27.2 ± 3.9 kg/m2; age: 46 ± 10 years) with acute, unilateral ATR were assessed at 8, 12, and 16 weeks after percutaneous surgical repair. To characterize the component tissues of the muscle-tendon unit, resting medial gastrocnemius muscle thickness, fascicle length, and pennation angle were determined from ultrasound images with the ankle in both maximal plantarflexion and dorsiflexion. The ankle range of motion (ROM) was determined using motion capture; combined ultrasound and motion capture determined the relative displacement of the musculotendinous junction (MTJ) of the AT with the medial gastrocnemius. The ATR-injured gastrocnemius muscle consistently exhibited lower thickness, regardless of time point and ankle angle. Maximal ankle plantarflexion angles and corresponding fascicle lengths were lower on the injured ankle compared to the contralateral throughout rehabilitation. When normalized to the overall ankle ROM, both injured fascicles and MTJ displacement exhibited a comparably lower change in length when the ankle was passively rotated. These results indicate that when both ankles are passively exposed to the same ROM following ATR surgery, both ipsilateral Achilles tendon and gastrocnemius muscle fascicles exhibit limited lengthening compared to the contralateral MTU tissues. This appears to be consistent throughout the rehabilitation of gait, suggesting that current post-operative rehabilitative exercises do not appear to induce muscle adaptations in the affected MTU

Time-Dependent Alterations of MMPs, TIMPs and Tendon Structure in Human Achilles Tendons after Acute Rupture

A balance between matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) is required to maintain tendon homeostasis. Variation in this balance over time might impact on the success of tendon healing. This study aimed to analyze structural changes and the expression profile of MMPs and TIMPs in human Achilles tendons at different time-points after rupture. Biopsies from 37 patients with acute Achilles tendon rupture were taken at surgery and grouped according to time after rupture: early (2–4 days), middle (5–6 days), and late (≥7 days), and intact Achilles tendons served as control. The histological score increased from the early to the late time-point after rupture, indicating the progression towards a more degenerative status. In comparison to intact tendons, qRT-PCR analysis revealed a significantly increased expression of MMP-1, -2, -13, TIMP-1, COL1A1, and COL3A1 in ruptured tendons, whereas TIMP-3 decreased. Comparing the changes over time post rupture, the expression of MMP-9, -13, and COL1A1 significantly increased, whereas MMP-3 and -10 expression decreased. TIMP expression was not significantly altered over time. MMP staining by immunohistochemistry was positive in the ruptured tendons exemplarily analyzed from early and late time-points. The study demonstrates a pivotal contribution of all investigated MMPs and TIMP-1, but a minor role of TIMP-2, -3, and -4, in the early human tendon healing process. View Full-Tex

Adult-Acquired Flatfoot Deformity: Combined Talonavicular Arthrodesis and Calcaneal Displacement Osteotomy versus Double Arthrodesis

Background: Adult-acquired flatfoot deformity due to posterior tibial tendon dysfunction (PTTD) is one of the most common foot deformities among adults. Hypothesis: Our study aimed to confirm that the combined procedures of calcaneal displacement osteotomy and talonavicular arthrodesis are equivalent to double arthrodesis. Methods: Between 2016 and 2020, 41 patients (13 male and 28 females, mean age of 63 years) were retrospectively enrolled in the comparative study. All deformities were classified into Stages II and III of PTTD, according to Johnson and Strom. All patients underwent isolated bony realignment of the deformity: group A (n = 19) underwent calcaneal displacement osteotomy and talonavicular arthrodesis, and group B (n = 23) underwent double arthrodesis. Measurements from the Foot Function Index-D (FFI-D) and the SF-12 questionnaire were collected, with a comparison of pre- and post-operative radiographs conducted. The mean follow-up period for patients was 3.4 years. Results: The mean FFI-D was 33.9 (group A: 34.5; group B: 33.5), the mean SF-12 physical component summary was 43.13 (group A: 40.9; group B: 44.9), and the mean SF-12 mental component summary was 43.13 (group A: 40.9; group B: 44.9). The clinical data and corrected angles showed no significant intergroup differences. Conclusion: Based on the available data, our study confirmed that the combined procedures of talonavicular arthrodesis and calcaneal shift, with preservation of the subtalar joint, can be considered equivalent to the established double arthrodesis, with no significant differences in terms of clinical and radiological outcomes

The Conventional Weil Osteotomy Does Not Require Screw Fixation

The Weil osteotomy is an established procedure to reduce plantar pressure in chronic metatarsalgia. Historically, the refixation of the displaced metatarsal head is performed by screw fixation. We aimed to demonstrate that screw fixation is not always necessary. Between 2016 and 2021, 155 patients with 278 Weil osteotomies (20 males and 135 females, mean age: 63 years) were retrospectively enrolled. Group A (n = 96) underwent 195 Weil osteotomies with screw fixation; group B (n = 59), 83 without screw fixation. Demographic, Visual Analog Scale Foot and Ankle (VAS-FA), SF-12 questionnaire, and toe mobility data were recorded. The mean follow-up period was 4.5 years. The mean VAS-FA was 75.5; mean SF-12 physical component summary, 42.0; and mean SF-12 mental component summary, 51.0. The overall revision rate was 20% (group A: 25%, group B: 10.2%), primarily for arthrolysis of the metatarsophalangeal joint in group A. Clinical comparisons showed no significant difference between the groups (p > 0.05). The revision rate was significantly higher in group A (p < 0.05), with equal satisfaction in clinical outcomes. Based on the available data, the need for regular screw fixation after a Weil osteotomy cannot be justified

A 10-Year Follow-Up of Ankle Syndesmotic Injuries: Prospective Comparison of Knotless Suture-Button Fixation and Syndesmotic Screw Fixation

Background: Acute syndesmosis injury (ASI) is an indication for surgical stabilization if instability is confirmed. In recent years, fixation using the knotless suture-button (SB) device has become increasingly established as an alternative to set screw fixation (SF). This study directly compared the clinical long-term results after prospective randomized inclusion. Materials and Methods: Between 2011 and 2012, 62 patients with ASI were enrolled in a prospective, randomized, and monocentric study. Forty-one patients were available for a 10-year follow-up ((31 males and 10 females), including 21 treated with SB (mean age 44.4 years), and 20 with SF (mean age 47.2 years)). In addition to comparing the demographic data and syndesmosis injury etiology, follow-up assessed the Olerud–Molander Ankle Score (OMAS) and FADI-Score (Foot and Ankle Disability Index Score) with subscales for activities of daily living (ADL) and sports activity. Results: The mean OMAS was 95.98 points (SB: 98.81, SF: 93.00), the mean FADI ADL was 97.58 points (SB: 99.22, SF: 95.86), and the mean FADI Sport was 94.14 points (SB: 97.03, SF: 91.10). None of the measurements differed significantly between the groups (p > 0.05). No clinical suspicion of chronic instability remained in any of the patients, regardless of treatment. Conclusions: The short-term results showed that athletes in particular benefit from SB fixation due to their significantly faster return to sports activities. However, the available long-term results confirm a very good outcome in the clinical scores for both approaches. Chronic syndesmotic insufficiency was not suspected in any of the patients. Level of evidence: I, randomized controlled trial

Different Achilles Tendon Pathologies Show Distinct Histological and Molecular Characteristics

Reasons for the development of chronic tendon pathologies are still under debate and more basic knowledge is needed about the different diseases. The aim of the present study was therefore to characterize different acute and chronic Achilles tendon disorders. Achilles tendon samples from patients with chronic tendinopathy (n = 7), chronic ruptures (n = 6), acute ruptures (n = 13), and intact tendons (n = 4) were analyzed. The histological score investigating pathological changes was significantly increased in tendinopathy and chronic ruptures compared to acute ruptures. Inflammatory infiltration was detected by immunohistochemistry in all tendon pathology groups, but was significantly lower in tendinopathy compared to chronic ruptures. Quantitative real-time PCR (qRT-PCR) analysis revealed significantly altered expression of genes related to collagens and matrix modeling/remodeling (matrix metalloproteinases, tissue inhibitors of metalloproteinases) in tendinopathy and chronic ruptures compared to intact tendons and/or acute ruptures. In all three tendon pathology groups markers of inflammation (interleukin (IL) 1β, tumor necrosis factor α, IL6, IL10, IL33, soluble ST2, transforming growth factor β1, cyclooxygenase 2), inflammatory cells (cluster of differentaition (CD) 3, CD68, CD80, CD206), fat metabolism (fatty acid binding protein 4, peroxisome proliferator-activated receptor γ, CCAAT/enhancer-binding protein α, adiponectin), and innervation (protein gene product 9.5, growth associated protein 43, macrophage migration inhibitory factor) were detectable, but only in acute ruptures significantly regulated compared to intact tendons. The study gives an insight into structural and molecular changes of pathological processes in tendons and might be used to identify targets for future therapy of tendon pathologies

Functional outcome and complication rate after percutaneous suture of fresh Achilles tendon ruptures with the Dresden instrument

Abstract Background The aim of this study was to evaluate the outcome of patients with a rupture of the Achilles tendon (ATR) treated percutaneously with the Dresden instrument in the hands of surgeons others than its inventors. Materials and methods 118 patients (FU rate: 77.1%) with an acute ATR treated with the Dresden instrument were retrospectively evaluated. The following data were evaluated: pain intensity, functional limitation, Hannover score, Achilles tendon total rupture score (ATRS), AOFAS ankle-hindfoot score, Tegner activity score, complications, maximum calf circumference (MCC) on both sides, and the Matles test for tendon lengthening. The effect of the time point of the surgery after trauma was examined. Results Hannover scores and ATRSs were good; AOFAS scores were excellent. Almost all patients returned to sporting activities postoperatively, and 66.1% were able to return to their previous level. The Tegner activity score revealed a slight posttraumatic decrease (p = 0.009) in the level of physical activity overall (pre-injury: 5.37 ± 0.15; postoperatively: 4.77 ± 0.15). The re-rupture rate was 2%. No sural nerve lesions and no infections were reported. Even after 3 years, there was still a difference in MCC that was correlated with inferior clinical score and AT lengthening. Patients treated within the first 2 days after ATR showed inferior clinical outcomes in terms of AOFAS score, ATRS, and functional limitations. Conclusions Percutaneous ATR suture with the Dresden instrument is a safe and reliable method. Low complication and re-rupture rates, good clinical results, and a high rate of return to play support this fact. The time point of the operation may influence the outcome

What about the others: differential diagnosis of COVID-19 in a German emergency department

Background!#!The ongoing COVID-19 pandemic remains a major challenge for worldwide health care systems and in particular emergency medicine. An early and safe triage in the emergency department (ED) is especially crucial for proper therapy. Clinical symptoms of COVID-19 comprise those of many common diseases; thus, differential diagnosis remains challenging.!##!Method!#!We performed a retrospective study of 314 ED patients presenting with conceivable COVID-19 symptoms during the first wave in Germany. All were tested for COVID-19 with SARS-Cov-2-nasopharyngeal swabs. Forty-seven patients were positive. We analyzed the 267 COVID-19 negative patients for their main diagnosis and compared COVID-19 patients with COVID-19 negative respiratory infections for differences in laboratory parameters, symptoms, and vital signs.!##!Results!#!Among the 267 COVID-19 negative patients, 42.7% had respiratory, 14.2% had other infectious, and 11.2% had cardiovascular diseases. Further, 9.0% and 6.7% had oncological and gastroenterological diagnoses, respectively. Compared to COVID-19 negative airway infections, COVID-19 patients showed less dyspnea (OR 0.440; p = 0.024) but more dysgeusia (OR 7.631; p = 0.005). Their hospital stay was significantly longer (9.0 vs. 5.6 days; p = 0.014), and their mortality significantly higher (OR 3.979; p = 0.014).!##!Conclusion!#!For many common ED diagnoses, COVID-19 should be considered a differential diagnosis. COVID-19 cannot be distinguished from COVID-19 negative respiratory infections by clinical signs, symptoms, or laboratory results. When hospitalization is necessary, the clinical course of COVID-19 airway infections seems to be more severe compared to other respiratory infections.!##!Trial registration!#!German Clinical Trial Registry DRKS, DRKS-ID of the study: DRKS00021675 date of registration: May 8th, 2020, retrospectively registered