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Paper #92 Functional bracing vs surgical repair for the treatment of Achilles tendon ruptures
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ABSTRACTS
bursitis. Patients must be monitored closely after surgery to prevent overuse of the healing Achilles tendon.
Paper #90 Extracorporeal Shock Wave Therapy (ESWT) In Patients With Painful, Proximal Plantar Fasciitis. Dietrich S. Hammer, Homburg/Saar, Germany, Frank Adam, Homburg/Saar, Germany, Stefan Rupp, Homburg/Saar, Germany, Andreas K. Kreutz, Presenter, Orthopaedic University Hospital, Homburg/Saar, Germany, Dieter M. Kohn, Homburg-Saar, Germany, Romain Seil, Homburg/Saar, Germany Objective: The aim of this study was to compare the effect of extracorporeal shock wave therapy (ESWT) in patients with chronically painful, proximal plantar fasciitis with a conventional conservative treatment. Methods: Forty-seven patients (49 heels) with a previously unsuccessful conservative treatment of at least 6 months were prospectively randomized to two groups with a random list. Treatment of group 1 (25 heels) started immediately after enrollment with three sessions of ESWT (3000 shock waves/session of 0.2 mJ/mm2) at weekly intervals. No local anaesthesia was applied. In the patients of group 2 (24 heels) conservative treatment was continued for 12 weeks. After this period they were treated using the protocol of group 1. Patients were followed up at 6, 12 and 24 weeks and 2 years after ESWT. A clinical investigation was performed regarding pain on a visual analogue scale ranging from 0 (no pain) to 100 (maximal pain) and the comfortable walking time. Statistical analysis was done with the non-parametrical Wilcoxon test for paired samples and the non-parametrical Mann-Whitney test for unpaired samples. Results: No significant difference of pain (70.2 ⫾ 22.4 to 70.2 ⫾ 22.2) and comfortable walking time (0.3h ⫾ 0.5 to 0.3h ⫾ 0.5) after further conservative treatment (3 months) was seen (group 2). Six months after ESWT pain during activities of daily living decreased by 83% on the visual analogue scale (VAS) and the comfortable walking time had increased significantly in both groups (p ⬍ 0.01). Two years after ESWT pain during activities of daily living had decreased even more by 90% on the visual analogue scale compared to prior to ESWT and the comfortable walking time had increased significantly in both groups (p ⬍ 0.01). Conclusion: In our study we could not find any significant differences of pain and walking time after further conservative treatment of 3 months in patients with chronic proximal plantar fasciitis. After ESWT pain and walking time improved significantly.
Paper #91 Normalized Tendon Structure And Decreased Thickness After Eccentric Training In Patients With Chronic Painful Achilles Tendinosis. ¨ hberg, Presenter, Dept of Diag. Radiology/ Lars O Dept of Surgical and Perioper, Umeå, Sweden, Ronny Lorentzon, Umeå, Sweden, Håkan Kjell, Umeå, Sweden, Bertil Alfredson, Umeå, Sweden Objective: To prospectively investigate tendon thickness and tendon structure by ultrasonography in patients treated with eccentric calf muscle training for painful chronic Achilles tendinosis located at the 2-6 cm level in the tendon. Methods: The patients were examined with greyscale ultrasonography before and after the 12-week eccentric training regimen. At follow-up, a questionnaire assessing present activity level and satisfaction with treatment was also used. Results: Twenty-six tendons in twenty-five patients (19 men and 6 women) with a mean age of 50-years were followed for a mean of 3.8 years (range 1.6-7.75 years). All patients had a long duration of pain symptoms (mean 17.1 months) from chronic Achilles tendinosis. At follow-up, 22 out of 25 patients were satisfied with treatment and active in Achilles tendon loading activities at desired level. The results of the ultrasonograhic examination showed that the tendon thickness (at the widest part) had decreased significantly (p ⬍ 0.005) between the measurements before and after treatment (8.8 ⫾ 3 mm and 7.6 ⫾ 2.3 mm (mean ⫾ SD), respectively), in the tendons with tendinosis. In the non-treated normal tendons, there was no significant difference in tendon thickness between the measurements (5.3 ⫾ 1.3 mm and 5.9 ⫾ 0.8 (mean ⫾ SD), respectively). All tendons with tendinosis had structural abnormalities (hypo-echoic areas and irregular structure) before start of treatment. After treatment (at follow-up), the tendon structure was normalised in 19 of the 26 tendons. In 6 out of the 7 tendons with remaining structural tendon abnormalities, the patients experienced pain-symptoms in the tendon during loading. Conclusions: For patients with painful chronic Achilles tendinosis, treatment with eccentric calf muscle training is associated with a localised decrease in tendon thickness, and a normalised tendon structure. Remaining structural tendon abnormalities seems to be associated with remaining pain-symptoms from the tendon. Paper #92 Functional Bracing Vs Surgical Repair For The Treatment Of Achilles Tendon Ruptures. Jay Adlington, Vancouver, Canada, Annunziato Amendola, Presenter, Fowler Kennedy Sport Medi-
ABSTRACTS cine Clinic, London, Canada, Ian Jones, London, Canada, Alexandra Kirkley, London, Canada, Sharon Griffin, London, Canada, Peter J. Fowler, London, Canada, Kenneth E. De Haven, Rochester, NY, USA Purpose: To compare clinical and functional performance measures in patients having undergone either surgical repair or functional bracing for complete rupture of the Achilles tendon. Method: A prospective sample of 12 patients with a rupture of the Achilles tendon were managed non-operatively with a functional bracing protocol at one centre (University of Rochester Medical Centre) and a group of age, gender, time since injury, and activity-matched controls with the same injury were managed with a standardized surgical repair at another centre (University of Western Ontario). Both groups followed similar immobilization and rehabilitation protocols. Outcomes included subjective responses to a questionnaire, clinical measurements of the range of motion of the ankle, and ground-reaction forces and temporal data gathered during functional dynamic activities that included walking, a single-limb power hop, and a single-limb heel rise endurance test. Results: Subjects were similar in both groups with respect to gender (11M, 1F), age (surgical ⫽ 39.9 yrs, bracing ⫽ 40.3 yrs), and time since injury (surgical ⫽ 3.3 yrs, bracing ⫽ 2.7 yrs). Subjective assessment of the treatment was rated as excellent (surgery ⫽ 9, bracing ⫽ 9), good (surgical ⫽ 2, bracing ⫽ 3), and fair (surgical ⫽ 1). Passive ankle plantar flexion was found to be decreased in both groups in comparison to the contralateral leg (surgical ⫽ 4.9o, bracing ⫽ 1.7o). Passive ankle dorsiflexion was decreased in comparison to the contralateral leg by 4.6o in the surgical group and increased by 2.0o in the bracing group. This difference was found to be statistically significant (p ⫽ 0.02). With the numbers available, we could detect no significant differences between the groups with regard to any of the kinetic or temporal variables that were measured during functional dynamic activities. Conclusions: With the numbers available, surgical repair of the Achilles tendon demonstrates no difference in clinical or functional outcome compared to functional bracing with the exception of an increase in passive dorsiflexion in the non-operative group. Paper #93 John Joyce Award Finalist Mechanical And Histological Analysis Of The Chronically Relaxed ACL After Thermal Radio-frequency Shrinkage In A Sheep Model. Sven U. Scheffler, Presenter, Department
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of Sports Traumatology and Arthroscopy, Berlin, Germany, Veronika Schoenfelder, Berlin, Germany, Patrick Hunt, Berlin, Germany, Heike Chwastek, Berlin, Germany, Norbert Suedkamp, Freiburg, Germany, Andreas Weiler, Berlin, Germany Purpose: Examination of radio frequency (RF) application for shrinkage of the chronically relaxed anterior cruciate ligament (ACL) and analysis of the mechanical and histological properties after such treatment. Methods: The tibial insertion of the ACL of 16 Marino sheep was surgically elevated simulating ACL elongation. The eminentia intercondylaris was elevated by a rectangular osteotomy and fixed with a bicortical screw. Thermal shrinkage of the ACL was carried out in 8 specimens using a monopolar RF device (Karl Storz Endoscopy, Tuttlingen, Germany). This treatment was continued until manual anterior-posterior (A-P) drawer testing revealed no increase in knee laxity. An achillotenotomy was performed to reduce load bearing and to simulate careful rehabilitation. At 24 weeks all animals were sacrificed and each knee underwent mechanical testing at 60° of flexion. First, A-P displacement under ⫾ 50 N load was measured, followed by a load-to-failure test with measurements of stiffness and failure load. At time zero, mechanical properties were compared between the intact, chronically relaxed and the RF treated ACLs. Cell numbers and vascular density of the ACL in each group were also histologically examined. Statistical analysis was performed using the Mann-Whitney-U Test. Level of statistical significance was set at p ⬍ 0.05. Results: A significant increase was found for A-P displacement (⫹202%) comparing the ACL relaxed untreated group with the ACL intact group (p ⬍ 0.001). Following thermal shrinkage, A-P displacement of the RF treated group (2.94 ⫾ 0.69 mm) was reduced to nearly the level of the intact ACL specimens (2.31 ⫾ 0.52 mm). At 24 weeks, a significantly lower stiffness and failure load were observed for the RF treated group (105 ⫾ 51 N/mm and 445 ⫾ 203 N) when compared to the ACL relaxed untreated group (143 ⫾ 31 N/mm and 788 ⫾ 305 N). A significant difference for A-P displacement could not be found between these two groups (4.68 ⫾ 1.99 mm vs. 4.19 ⫾ 0.86 mm). At 24 weeks, cell numbers were significantly reduced in the midportion of the ACLs in the RF treated group compared to the relaxed untreated ACLs. The same relationship was found for vascularity with significantly lower vessel density in the RF treated group. Subsynovial hypervascularity was found in each group, with no differences between the RF treated and relaxed untreated ACLs.
ABSTRACTS
bursitis. Patients must be monitored closely after surgery to prevent overuse of the healing Achilles tendon.
Paper #90 Extracorporeal Shock Wave Therapy (ESWT) In Patients With Painful, Proximal Plantar Fasciitis. Dietrich S. Hammer, Homburg/Saar, Germany, Frank Adam, Homburg/Saar, Germany, Stefan Rupp, Homburg/Saar, Germany, Andreas K. Kreutz, Presenter, Orthopaedic University Hospital, Homburg/Saar, Germany, Dieter M. Kohn, Homburg-Saar, Germany, Romain Seil, Homburg/Saar, Germany Objective: The aim of this study was to compare the effect of extracorporeal shock wave therapy (ESWT) in patients with chronically painful, proximal plantar fasciitis with a conventional conservative treatment. Methods: Forty-seven patients (49 heels) with a previously unsuccessful conservative treatment of at least 6 months were prospectively randomized to two groups with a random list. Treatment of group 1 (25 heels) started immediately after enrollment with three sessions of ESWT (3000 shock waves/session of 0.2 mJ/mm2) at weekly intervals. No local anaesthesia was applied. In the patients of group 2 (24 heels) conservative treatment was continued for 12 weeks. After this period they were treated using the protocol of group 1. Patients were followed up at 6, 12 and 24 weeks and 2 years after ESWT. A clinical investigation was performed regarding pain on a visual analogue scale ranging from 0 (no pain) to 100 (maximal pain) and the comfortable walking time. Statistical analysis was done with the non-parametrical Wilcoxon test for paired samples and the non-parametrical Mann-Whitney test for unpaired samples. Results: No significant difference of pain (70.2 ⫾ 22.4 to 70.2 ⫾ 22.2) and comfortable walking time (0.3h ⫾ 0.5 to 0.3h ⫾ 0.5) after further conservative treatment (3 months) was seen (group 2). Six months after ESWT pain during activities of daily living decreased by 83% on the visual analogue scale (VAS) and the comfortable walking time had increased significantly in both groups (p ⬍ 0.01). Two years after ESWT pain during activities of daily living had decreased even more by 90% on the visual analogue scale compared to prior to ESWT and the comfortable walking time had increased significantly in both groups (p ⬍ 0.01). Conclusion: In our study we could not find any significant differences of pain and walking time after further conservative treatment of 3 months in patients with chronic proximal plantar fasciitis. After ESWT pain and walking time improved significantly.
Paper #91 Normalized Tendon Structure And Decreased Thickness After Eccentric Training In Patients With Chronic Painful Achilles Tendinosis. ¨ hberg, Presenter, Dept of Diag. Radiology/ Lars O Dept of Surgical and Perioper, Umeå, Sweden, Ronny Lorentzon, Umeå, Sweden, Håkan Kjell, Umeå, Sweden, Bertil Alfredson, Umeå, Sweden Objective: To prospectively investigate tendon thickness and tendon structure by ultrasonography in patients treated with eccentric calf muscle training for painful chronic Achilles tendinosis located at the 2-6 cm level in the tendon. Methods: The patients were examined with greyscale ultrasonography before and after the 12-week eccentric training regimen. At follow-up, a questionnaire assessing present activity level and satisfaction with treatment was also used. Results: Twenty-six tendons in twenty-five patients (19 men and 6 women) with a mean age of 50-years were followed for a mean of 3.8 years (range 1.6-7.75 years). All patients had a long duration of pain symptoms (mean 17.1 months) from chronic Achilles tendinosis. At follow-up, 22 out of 25 patients were satisfied with treatment and active in Achilles tendon loading activities at desired level. The results of the ultrasonograhic examination showed that the tendon thickness (at the widest part) had decreased significantly (p ⬍ 0.005) between the measurements before and after treatment (8.8 ⫾ 3 mm and 7.6 ⫾ 2.3 mm (mean ⫾ SD), respectively), in the tendons with tendinosis. In the non-treated normal tendons, there was no significant difference in tendon thickness between the measurements (5.3 ⫾ 1.3 mm and 5.9 ⫾ 0.8 (mean ⫾ SD), respectively). All tendons with tendinosis had structural abnormalities (hypo-echoic areas and irregular structure) before start of treatment. After treatment (at follow-up), the tendon structure was normalised in 19 of the 26 tendons. In 6 out of the 7 tendons with remaining structural tendon abnormalities, the patients experienced pain-symptoms in the tendon during loading. Conclusions: For patients with painful chronic Achilles tendinosis, treatment with eccentric calf muscle training is associated with a localised decrease in tendon thickness, and a normalised tendon structure. Remaining structural tendon abnormalities seems to be associated with remaining pain-symptoms from the tendon. Paper #92 Functional Bracing Vs Surgical Repair For The Treatment Of Achilles Tendon Ruptures. Jay Adlington, Vancouver, Canada, Annunziato Amendola, Presenter, Fowler Kennedy Sport Medi-
ABSTRACTS cine Clinic, London, Canada, Ian Jones, London, Canada, Alexandra Kirkley, London, Canada, Sharon Griffin, London, Canada, Peter J. Fowler, London, Canada, Kenneth E. De Haven, Rochester, NY, USA Purpose: To compare clinical and functional performance measures in patients having undergone either surgical repair or functional bracing for complete rupture of the Achilles tendon. Method: A prospective sample of 12 patients with a rupture of the Achilles tendon were managed non-operatively with a functional bracing protocol at one centre (University of Rochester Medical Centre) and a group of age, gender, time since injury, and activity-matched controls with the same injury were managed with a standardized surgical repair at another centre (University of Western Ontario). Both groups followed similar immobilization and rehabilitation protocols. Outcomes included subjective responses to a questionnaire, clinical measurements of the range of motion of the ankle, and ground-reaction forces and temporal data gathered during functional dynamic activities that included walking, a single-limb power hop, and a single-limb heel rise endurance test. Results: Subjects were similar in both groups with respect to gender (11M, 1F), age (surgical ⫽ 39.9 yrs, bracing ⫽ 40.3 yrs), and time since injury (surgical ⫽ 3.3 yrs, bracing ⫽ 2.7 yrs). Subjective assessment of the treatment was rated as excellent (surgery ⫽ 9, bracing ⫽ 9), good (surgical ⫽ 2, bracing ⫽ 3), and fair (surgical ⫽ 1). Passive ankle plantar flexion was found to be decreased in both groups in comparison to the contralateral leg (surgical ⫽ 4.9o, bracing ⫽ 1.7o). Passive ankle dorsiflexion was decreased in comparison to the contralateral leg by 4.6o in the surgical group and increased by 2.0o in the bracing group. This difference was found to be statistically significant (p ⫽ 0.02). With the numbers available, we could detect no significant differences between the groups with regard to any of the kinetic or temporal variables that were measured during functional dynamic activities. Conclusions: With the numbers available, surgical repair of the Achilles tendon demonstrates no difference in clinical or functional outcome compared to functional bracing with the exception of an increase in passive dorsiflexion in the non-operative group. Paper #93 John Joyce Award Finalist Mechanical And Histological Analysis Of The Chronically Relaxed ACL After Thermal Radio-frequency Shrinkage In A Sheep Model. Sven U. Scheffler, Presenter, Department
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of Sports Traumatology and Arthroscopy, Berlin, Germany, Veronika Schoenfelder, Berlin, Germany, Patrick Hunt, Berlin, Germany, Heike Chwastek, Berlin, Germany, Norbert Suedkamp, Freiburg, Germany, Andreas Weiler, Berlin, Germany Purpose: Examination of radio frequency (RF) application for shrinkage of the chronically relaxed anterior cruciate ligament (ACL) and analysis of the mechanical and histological properties after such treatment. Methods: The tibial insertion of the ACL of 16 Marino sheep was surgically elevated simulating ACL elongation. The eminentia intercondylaris was elevated by a rectangular osteotomy and fixed with a bicortical screw. Thermal shrinkage of the ACL was carried out in 8 specimens using a monopolar RF device (Karl Storz Endoscopy, Tuttlingen, Germany). This treatment was continued until manual anterior-posterior (A-P) drawer testing revealed no increase in knee laxity. An achillotenotomy was performed to reduce load bearing and to simulate careful rehabilitation. At 24 weeks all animals were sacrificed and each knee underwent mechanical testing at 60° of flexion. First, A-P displacement under ⫾ 50 N load was measured, followed by a load-to-failure test with measurements of stiffness and failure load. At time zero, mechanical properties were compared between the intact, chronically relaxed and the RF treated ACLs. Cell numbers and vascular density of the ACL in each group were also histologically examined. Statistical analysis was performed using the Mann-Whitney-U Test. Level of statistical significance was set at p ⬍ 0.05. Results: A significant increase was found for A-P displacement (⫹202%) comparing the ACL relaxed untreated group with the ACL intact group (p ⬍ 0.001). Following thermal shrinkage, A-P displacement of the RF treated group (2.94 ⫾ 0.69 mm) was reduced to nearly the level of the intact ACL specimens (2.31 ⫾ 0.52 mm). At 24 weeks, a significantly lower stiffness and failure load were observed for the RF treated group (105 ⫾ 51 N/mm and 445 ⫾ 203 N) when compared to the ACL relaxed untreated group (143 ⫾ 31 N/mm and 788 ⫾ 305 N). A significant difference for A-P displacement could not be found between these two groups (4.68 ⫾ 1.99 mm vs. 4.19 ⫾ 0.86 mm). At 24 weeks, cell numbers were significantly reduced in the midportion of the ACLs in the RF treated group compared to the relaxed untreated ACLs. The same relationship was found for vascularity with significantly lower vessel density in the RF treated group. Subsynovial hypervascularity was found in each group, with no differences between the RF treated and relaxed untreated ACLs.