| 1. |
- Alim, Md Abdul, et al.
(författare)
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Achilles tendon rupture healing is enhanced by intermittent pneumatic compression upregulating collagen type I synthesis
- 2018
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Ingår i: Knee Surgery, Sports Traumatology, Arthroscopy. - : Springer Science and Business Media LLC. - 0942-2056 .- 1433-7347. ; 26:7, s. 2021-2029
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE AND HYPOTHESIS: Adjuvant intermittent pneumatic compression (IPC) during leg immobilization following Achilles tendon rupture (ATR) has been shown to reduce the risk of deep venous thrombosis. The purpose of this study was to investigate whether IPC can also promote tendon healing.METHODS: One hundred and fifty patients with surgical repair of acute ATR were post-operatively leg immobilized and prospectively randomized. Patients were allocated for 2 weeks of either adjuvant IPC treatment (n = 74) or treatment-as-usual (n = 74) in a plaster cast without IPC. The IPC group received 6 h daily bilateral calf IPC applied under an orthosis on the injured side. At 2 weeks post-operatively, tendon healing was assessed using microdialysis followed by enzymatic quantification of tendon callus production, procollagen type I (PINP) and type III (PIIINP) N-terminal propeptide, and total protein content. 14 IPC and 19 cast patients (control group) consented to undergo microdialysis. During weeks 3-6, all subjects were leg-immobilized in an orthosis without IPC. At 3 and 12 months, patient-reported outcome was assessed using reliable questionnaires (ATRS and EQ-5D). At 12 months, functional outcome was measured using the validated heel-rise test.RESULTS: At 2 weeks post-rupture, the IPC-treated patients exhibited 69% higher levels of PINP in the ruptured Achilles tendon (AT) compared to the control group (p = 0.001). Interestingly, the IPC-treated contralateral, intact AT also demonstrated 49% higher concentrations of PINP compared to the non-treated intact AT of the plaster cast group (p = 0.002). There were no adverse events observed associated with IPC. At 3 and 12 months, no significant (n.s.) differences between the two treatments were observed using patient-reported and functional outcome measures.CONCLUSIONS: Adjuvant IPC during limb immobilization in patients with ATR seems to effectively enhance the early healing response by upregulation of collagen type I synthesis, without any adverse effects. Whether prolonged IPC application during the whole immobilization period can also lead to improved long-term clinical healing response should be further investigated. The healing process during leg immobilization in patients with Achilles tendon rupture can be improved through adjuvant IPC therapy, which additionally prevents deep venous thrombosis.LEVEL OF EVIDENCE: Randomized controlled trial, Level I.
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| 2. |
- Domeij Arverud, Erica
(författare)
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Acute achilles tendon rupture : predictors and intervention to promote outcome
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- 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.
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| 3. |
- Domeij-Arverud, Erica, et al.
(författare)
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Ageing, deep vein thrombosis and male gender predict poor outcome after acute Achilles tendon rupture
- 2016
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Ingår i: The Bone & Joint Journal. - Stockholm : Karolinska Institutet, Dept of Molecular Medicine and Surgery. - 2049-4394. ; 98B98-B:12, s. 1635-1641
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 4. |
- Domeij-Arverud, Erica, et al.
(författare)
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Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation : a prospective randomised trial of acute ruptures of the Achilles tendon
- 2015
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Ingår i: The Bone & Joint Journal. - Stockholm : Karolinska Institutet, Dept of Molecular Medicine and Surgery. - 2049-4394. ; 97B97-B:5, s. 675-680
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Tidskriftsartikel (refereegranskat)abstract
- Deep vein thrombosis is a common complication when immobilising the lower limb after surgery. We hypothesised that adjuvant intermittent pneumatic compression (IPC) during post-operative outpatient immobilisation of the lower limb could reduce the incidence of deep vein thrombosis (DVT). A total of 150 patients with acute Achilles tendon rupture were randomised to either treatment with IPC for six hours daily (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast. At two weeks post-operatively the incidence of DVT was assessed using compression duplex ultrasound (CDU) by two ultrasonographers blinded to treatment. After the IPC intervention had ended, all patients were immobilised in the orthosis for another four weeks and a second CDU was performed. Trial registration: www.clinicaltrials.gov; NCT01317160. At two weeks the DVT rate was 21% in the IPC group and 38% in the control group (OR = 2.36; 95% CI 1.11 to 5.01). Age > 39 years was found to be a strong risk factor for DVT (OR = 4.84; 95% CI 2.14 to 10.96). Treatment with IPC corrected for age reduced the risk significantly (OR = 0.36; 95% CI 0.16 to 0.80). At six weeks, however, the frequency of DVT was 49% in the IPC group and 51% in the control group (OR = 0.94; 95% CI 0.49 to 1.83). IPC seems to be an effective method of reducing the risk of early DVT in leg-immobilised outpatients. A high risk of DVT during prolonged immobilisation warrants further study.
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| 5. |
- Svedman, Simon, et al.
(författare)
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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
- 2021
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Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:5
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Tidskriftsartikel (refereegranskat)abstract
- 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 analys: 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.
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