D922etukansi.kesken.fm Page 1 Tuesday, April 17, 2007 11:51 AM D OULU 2007 D 922 9 2 2 ACTA UNIVERSITY OF OULU P.O. Box 7500 FI-90014 UNIVERSITY OF OULU FINLAND A UNIVERSITATIS OULUENSIS C D A C T A U N I V E R S I T A T I S O U L U E N S I S T A S E R I E S E D I T O R S Jarmo Kangas MEDICA A SCIENTIAE RERUM NATURALIUM J OUTCOME OF TOTAL a Professor Mikko Siponen r B m o ACHILLES TENDON HUMANIORA K a Professor Harri Mantila n RUPTURE REPAIR, WITH C g a s TECHNICA SPECIAL REFERENCE TO Professor Juha Kostamovaara D SUTURE MATERIALS AND MEDICA Professor Olli Vuolteenaho E POSTOPERATIVE SCIENTIAE RERUM SOCIALIUM TREATMENT Senior Assistant Timo Latomaa F SCRIPTAACADEMICA Communications Officer Elna Stjerna G OECONOMICA Senior Lecturer Seppo Eriksson EDITOR IN CHIEF Professor Olli Vuolteenaho EDITORIAL SECRETARY Publications Editor Kirsti Nurkkala FACULTY OF MEDICINE, DEPARTMENT OF SURGERY, DIVISION OF ORTHOPAEDIC AND TRAUMA SURGERY, ISBN 978-951-42-8433-5 (Paperback) UNIVERSITY OF OULU ISBN 978-951-42-8434-2 (PDF) ISSN 0355-3221 (Print) ISSN 1796-2234 (Online) ACTA UNIVERSITATIS OULUENSIS D Medica 922 JARMO KANGAS OUTCOME OF TOTAL ACHILLES TENDON RUPTURE REPAIR, WITH SPECIAL REFERENCE TO SUTURE MATERIALS AND POSTOPERATIVE TREATMENT Academic dissertation to be presented, with the assent of the Faculty of Medicine of the University of Oulu, for public defence in Auditorium 1 of Oulu University Hospital, on May 4th, 2007, at 12 noon OULUN YLIOPISTO, OULU 2007 Copyright © 2007 Acta Univ. Oul. D 922, 2007 Supervised by Docent Juhana Leppilahti Reviewed by Professor Markku Järvinen Docent Hannu Miettinen ISBN 978-951-42-8433-5 (Paperback) ISBN 978-951-42-8434-2 (PDF) http://herkules.oulu.fi/isbn9789514284342/ ISSN 0355-3221 (Printed) ISSN 1796-2234 (Online) http://herkules.oulu.fi/issn03553221/ Cover design Raimo Ahonen OULU UNIVERSITY PRESS OULU 2007 Kangas, Jarmo, Outcome of total Achilles tendon rupture repair, with special reference to suture materials and postoperative treatment Faculty of Medicine, Department of Surgery, Division of Orthopaedic and Trauma Surgery, University of Oulu, P.O.Box 5000, FI-90014 University of Oulu, Finland Acta Univ. Oul. D 922, 2007 Oulu, Finland Abstract The purposes of the present research were to compare the outcome after Achilles tendon rupture repair in two postoperative regimens, to compare Achilles tendon elongation in two postoperative treatment methods, to compare the effects of two postoperative methods on motor performance aspects such as simple reaction time, choice reaction time, speed of movement, foot tapping speed and coordination, to test the mechanical properties of the recently developed poly-L/D-lactide (PLDLA) sutures and Maxon® sutures when implanted in the Achilles tendons of rabbits, and to study the histological tissue reactions and biodegradation of these sutures under the same conditions. Isokinetic calf muscle strength scores at the last control check-up were excellent in 56% of the patients in the early motion group, good in 32%, fair in 8%, and poor in 4%, whereas the scores in the cast group were excellent in 29% of cases, good in 50% and fair in 21%. The ankle performance scores were excellent or good in 88% of the patients in the early motion group, fair in 4% and poor in 8%, whereas the scores in the cast group were excellent or good in 92% of cases and fair in 8%. No significant differences were seen between the two groups at 3 months and at the last control checkups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, isokinetic calf muscle strength or overall outcome. The complications included 1 re- rupture in the early motion group and 1 deep infection and 2 re-ruptures in the cast group. AT elongation occurred in both groups, but was somewhat less marked in the early motion group. The AT elongation curves rose at first and then fell slowly in both groups. The patients who had less AT elongation achieved a better clinical outcome. AT elongation did not correlate significantly with age, body mass index or isokinetic peak torques. The recovery of motor performance functions such as simple reaction time, choice reaction time, speed of movement, foot tapping speed and coordination did not depend on the two postoperative regimens. The motor functions of the operated leg had obviously recovered to the level of the non- operated leg 12 weeks after the operation. Sutures made of PLDLA were used successfully for Achilles tendon repair in rabbits. There was no significant difference between the in vitro and in vivo tensile strength retention of the sutures. By comparison with Maxon®, PLDLA was found to have a lower initial tensile strength but more prolonged strength retention. The breaking strength values of the Achilles tendons repaired with sutures of these types were not significantly different at 6 weeks. Intratendinous PLDLA sutures formed a thinner fibrous capsule during the 12-week follow-up period than did Maxon® sutures of the same diameter. The suture materials had not been totally absorbed by 12 weeks. Keywords: achilles tendon rupture, biocompatibility, early motion, histomorphometry, immobilization in tension, Maxon®, motor performance, Polylactide suture, postoperative regimens, tendon elongation, tendon repair Acknowledgements This work was carried out at the Department of Surgery, Division of Orthopaedics, Oulu University Hospital and at the Department of Physical Medicine and Rehabilitation dur- ing the years 1995–2007. I would like to thank warmly all the people who have influenced my work, one way or another, and thus contributed to this thesis: Docent Juhana Leppilahti, M.D., Ph.D., present Head of the Division of Orthopaedics, my supervisor, for valuable advices and criticism and for introducing me to scientific research. Professor Pekka Jalovaara, M.D., Ph.D., Docent Kari Haukipuro, M.D., Ph.D., Profes- sor Tatu Juvonen, M.D., Ph.D., Professor Martti Hämäläinen, M.D., Ph.D. and Docent Timo Niinimäki, M.D., Ph.D. for their support and advise. Professor Markku Järvinen, M.D., Ph.D and Docent Hannu Miettinen, M.D. Ph.D. for reviewing the manuscript and for constructive criticism and comments. Ari Pajala, M.D., Professor Nureddin Ashammakhi, MD, PhD, Pirkka Mäkelä M.D., Docent Kari Kauranen, Pertti Siira, PT, Satu Länsman M.D., Senja Paasimaa M.Sc., Docent Jorma Ryhänen, M.D., Ph.D., and Dosent Timo Waris M.D., PhD, my co-authors and work-partners for the support during my work for this thesis. Pasi Ohtonen, M.Sc., for sharing his knowledge on biostatistics. Mr Timo Pelimanni and Mr Paavo Pitkänen for their help to develop the immobilisa- tion brace. Malcolm Hicks, M.A., for excellent revision of the language of the original articles and the manuscript of this thesis. My dear parents Tuula and Mauri Kangas for love and support that never failed. Finally, I extend my deepest thanks to my dear wife Johanna, for her love, patience and comprehensive support during the years spent together, and to our lovely children Tuulia, Joonas, Milla, Roope and Roosa for reminding me of the most important things in life. Joensuu 6.4.2007 Jarmo Kangas Abbreviations AT Achilles tendon ATR Achilles tendon rupture DF Dorsiflexion HPM/BEP Human Performance Measurement/Basic Elements of Performance ICC Intraclass correlation coefficient of reliability MRI Magnetic resonance imaging PT Peak torque PTA Peak torque angle PW Peak work PL Plantar flexion SEM Standard error of measurement SD Standard deviation ROM Range of motion US Ultrasonography VAS Visual analogical scale