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Welcome back to The Sports Docs Podcast!  In this episode, we’re going to continue our discussion with Dr. Bonnie Chien and focus on surgical treatment for Achilles tendon ruptures.

Our conversation picks back up with an article from the March 2023 issue of AJSM titled “Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures.” This Level I meta-analysis included 10 RCTs and found no difference in AOFAS scores and rate of total complications, re-ruptures, deep infections, skin necrosis, wound dehiscence, adhesions or keloid scars. But there were some significant differences between the groups.

Open repair was associated with significantly longer surgical time, higher risk of superficial infections and higher risk of ankle stiffness. Minimally invasive repair was associated with a higher rate of sural nerve injury, 3.4% compared to 0% in the open group.

Next up is a level I RCT from the June 2020 issue of AJSM titled “Comparison of Tendon Lengthening With Traditional Versus Accelerated Rehabilitation After Achilles Tendon Repair.” Patients were randomized to either a traditional rehab group with weightbearing at 6 weeks or an accelerated rehab group with graduated weightbearing starting at 2 weeks. All patients were found to have tendon lengthening after surgery with no significant differences found in overall lengthening between traditional and accelerated rehab groups. There were also no differences noted in ankle range of motion or outcome scores between the groups.

We finished up with an article from the October 2017 issue of AJSM titled “Professional Athletes’ Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture.” This level III cohort study looked at return to play rates and performance among professional athletes after Achilles tendon repair in the NFL, NBA, MLB and NHL. The authors found that 30% of athletes with an isolated Achilles rupture were unable to return to play at all after surgical repair. Those that were able to return to play had significantly less play time, less game played and played significantly worse compared to their pre-op performance levels. NBA players were most affected.

On today’s episode we’re focusing on Achilles tendon ruptures with Dr. Bonnie Chien. We have some great articles for you that contribute well to our conversation on the optimal management of Achilles tendon ruptures and the different surgical approaches. As always, links to all of the papers that we discuss on this show can be found on our podcast website – www.thesportsdocspod.com

We’ll start off our discussion today with an article from the April 2012 issue of CORR titled “MRI is Unnecessary for Diagnosing Acute Achilles Tendon Ruptures.” Yes, it is an oldie. But we do think it sparks an interesting discussion about the utility of MRI in the setting of a clear Achilles tendon rupture.

This study retrospectively compared 66 patients with acute Achilles ruptures and pre-op MRI with a control group of 66 patients without a pre-op MRI who were indicated for surgery by clinical diagnostic criteria alone.

Criteria was: (1) an abnormal Thompson test, (2) decreased resting tension and (3) a palpable defect. The authors found that these clinical findings were 100% sensitive for a complete Achilles rupture.

It took patients an average of 5 days to obtain the MRI after injury and 12 days for surgical intervention. In comparison, patients in the control group were taken for surgery at an average of 5.6 days after injury. No additional procedures were required in the control group compared to 19 patients in the MRI group.

The authors concluded that physical exam was more sensitive than MRI and that MRI is time-consuming, expensive and can lead to treatment delays which may be associated with a need for additional procedures at the time of surgery.

Then, from the April 2022 issue of the New England Journal of Medicine, we review an article titled “Nonoperative or Surgical Treatment of Acute Achilles Tendon Rupture.” This multicenter randomized controlled trial compared nonoperative treatment, open repair, and minimally invasive repair in 554 patients with an acute Achilles tendon rupture. The authors concluded that that 12 months post-treatment, surgery was not associated with better outcomes than nonsurgical treatment. However, 11 patients in the nonoperative group sustained a re-rupture compared to 1 patient in the open repair group and 1 patient in the minimally invasive repair group.

We are joined today by Dr. Bonnie Chien, a board-certified orthopedic surgeon and Assistant Professor at Columbia University who specializes in foot and ankle conditions. She received her medical degree from Stanford University and then completed her orthopedic residency at Harvard Medical School with Catherine and I. She then went on to complete a foot and ankle fellowship at Mercy Medical Center in Baltimore. 

Dr. Chien is passionate about global health and has traveled internationally to teach and perform foot and ankle surgeries. She is fluent in Chinese and English and speaks conversational Spanish. Dr. Chien has lectured extensively on the topic of Achilles, so we’re very excited to hear all that she has to share on this topic today.

Today we’re going to give you an update pertaining to one of our favorite topics – ACL. And honestly, it’s been a bit since we done an episode on ACL so we’re excited to dive into this new paper today and talk more about how it will impact our practice. We’re going to review an article from the January issue of AJSM year titled “Risk of Revision and Reoperation After Quadriceps Tendon Autograft ACL Reconstruction Compared with Patellar Tendon and Hamstring Autografts in a US Cohort of 21,973 Patients.”

In this Overtime episode, The Sports Docs discuss the remplissage procedure and will be reviewing an article from the January issue of AJSM year titled “Stabilizing Mechanisms in Patients Treated Using Hill-Sachs Remplissage with Bankart Repair in Abduction–External Rotation Position.”

This study was performed by Dr. Fei Zhang and team in Beijing, China and analyzed the biomechanical effects of the remplissage procedure on glenohumeral alignment at rest and with active motion.

Our next poster is titled The Utility of Stress Ultrasound in Identifying Risk Factors for Elbow Ulnar Collateral Ligament Rupture: A Longitudinal Study of 203 Professional Baseball Players. This study was performed by your colleagues at the Rothman Institute and aimed to identify anatomic risk factors on dynamic ultrasound that may predispose players to future UCL injury. The authors found that players who ultimately required UCL reconstruction had greater ulnohumeral joint rest space, higher rates of hypoechoic foci and increased UCL thickness on ultrasound compared to players who did not require UCLR.

Our next poster is titled Primary Latarjet Procedure versus Latarjet in the Setting of Previously Failed Bankart Repair: A Systematic Review. We’ve spoken a lot about shoulder instability on this podcast, most recently with Yoni Rosenblatt last month discussing rehab tips and tricks after various shoulder stabilization surgeries. We also had Dr. Brian Lau on Episodes 48 and 49 to chat about the different surgical options for anterior shoulder instability. So, we’re excited to review this poster today and add some new literature to this discussion.