Longer duration of operative time enhances healing metabolites and improves patient outcome after Achilles tendon rupture surgery

Abstract

PurposeThe relationship between the duration of operative time (DOT), healing response and patient outcome has not been previously investigated. An enhanced healing response related to DOT may potentiate repair processes, especially in hypovascular and sparsely metabolized musculoskeletal tissues such as tendons. This study aimed to investigate the association between DOT and the metabolic healing response, patient-reported outcome and the rate of post-operative complications after acute Achilles tendon injury.MethodsObservational cohort, cross-sectional study with observers blinded to patient grouping. A total of two-hundred and fifty-six prospectively randomized patients (210 men, 46 women; mean age 41 years) with an acute total Achilles tendon rupture all operated on with uniform anaesthetic and surgical technique were retrospectively assessed. At 2 weeks post-operatively, six metabolites were quantified using microdialysis. At 3, 6 and 12 months, patient-reported pain, walking ability and physical activity were examined using self-reported questionnaires, Achilles tendon total rupture score, foot and ankle outcome score and physical activity scale. At 12 months, functional outcome was assessed using the heel-rise test. Complications, such as deep venous thrombosis, infections and re-operations, were recorded throughout the study.ResultsPatients who underwent longer DOT exhibited higher levels of glutamate (p = 0.026) and glycerol (p = 0.023) at 2 weeks. At the 1-year follow-up, longer DOT was associated with significantly less loss in physical activity (p = 0.003), less pain (p = 0.009), less walking limitations (p = 0.022) and better functional outcome (p = 0.014). DOT did not significantly correlate with the rate of adverse events, such as deep venous thrombosis, infections or re-ruptures. Higher glutamate levels were associated with less loss in physical activity (p = 0.017). All correlations were confirmed by multiple linear regressions taking confounding factors into consideration.ConclusionThe results from this study suggest a previously unknown mechanism, increased metabolic response associated with longer DOT, which may improve patient outcome after Achilles tendon rupture surgery. Allowing for a higher amount of traumatized tissue, as reflected by up-regulation of glycerol in patients with longer DOT, may prove to be an important surgical tip for stimulation of repair of hypometabolic soft tissue injuries, such as Achilles tendon ruptures.Level of evidenceII.Electronic supplementary materialThe online version of this article (doi:10.1007/s00167-017-4606-7) contains supplementary material, which is available to authorized users.

Reduced Time to Surgery Improves Patient-Reported Outcome After Achilles Tendon Rupture

“…An earlier study has demonstrated that at one year after ATR surgery 44% of the patients experienced limitations due to pain in their limb and 48% of the patients had limitations in walking on uneven surface. 22 It may prove that prolonged TTS diminishes the healing potential of the patient, which may lead to an increased experience of pain. The established worse subjective outcome after more than seventy-two hours' delay may therefore be related to the biology of tendon healing.…”

“…The surgical procedure was performed on an outpatient basis using uniform anesthetic and surgical techniques 22 as part of a standardized protocol for anesthesia and surgery, which was used in both RCTs 6,23 from which the patients in this study were selected. and peritendinous space.…”

Deep venous thrombosis after Achilles tendon rupture is associated with poor patient-reported outcome

“…Age have been demonstrated to increase the risk of venous thromboembolism (VTE) by 2% per increase in year [ 8 , 29 ]. Prolonged duration of operative time more than 60 min increases the risk of thrombosis according to NICE [ 1 ], but shorter duration of operative time after ATR has been demonstrated to hamper both subjective and functional outcome [ 34 ]. The observation that all these factors did not affect the reported results therefore corroborates the main results, showing that DVT has a negative effect on the patient-reported outcome.…”

Higher pyruvate levels after Achilles tendon rupture surgery could be used as a prognostic biomarker of an improved patient outcome

“…Patient included in the original trials underwent different post-operative treatments, which differed mainly during the first two post-operative weeks. Forty-two patients received treatment with plaster cast immobilization [ 9 ], 12 patients with calf intermittent pneumatic compression under an orthosis [ 6 ], 5 patients with foot intermittent pneumatic compression under plaster cast [ 9 ] and 50 patients with functional weight-bearing in an orthosis (VACO ® ped, OPED Gmbh, Germany) [ 3 , 25 , 27 ] (Table 2 ).…”