Patient population
39 patients (24 - non sport related persons,
without permanent sports activity and 15 athlets and balet dancers) with acute Achilles rupture after open surgical repair were included in the follow-up US with sonoelastography study.
The patients were 8 females and 31 males.
With a median age of the whole group 38.1±10.6 years (range 18–65).
First group (non athlets) with median age 39,9 +/- 6,7 years,
second group (athlets) - 35,6 +/- 9,7 years.
In all cases,
the rupture was located in the middle third of the tendon and was treated with open surgery.
28 had ruptures on the right side and 11 on the left side.
All patients: (Non athlets and athlets) had no diabetes mellitus,
cancer,
lung and heart diseases,
rheumatoid arthritis,
spondyloarthropathy,
and hypercholesterolemia due to the association between these factors and tendon abnormalities [8].
Rehabilitation programm
All patients received rehabilitation treatment in recommended amount according to time after surgery [9,10] supervised by the physiotherapist at our hospital’s center.
The rehabilitation program included non-weight-bearing cast immobilization with reduced equinus and toe motion for 6 weeks and a short leg cast with neutral ankle dorsiflexion from 6 to 8 weeks postoperatively.
After fitting with a partial weight-bearing,
removable cast boot or night splint from 8 to 12 weeks postoperatively,
patients completed a physical therapy program,
including proprioceptive and functional ankle recovery,
and cross-training.
The cast boot was discontinued at 12 weeks postoperatively.
Then patients sustained full weight-bearing followed by a physical therapy program,
including return to sport,
road running,
and cross-training.
Ultrasound examination
Each tendon was scanned in a prone position with the foot hanging over the edge of the examination bed in a neutral position to avoid tendon stress [11].
US examination with Sonoelastography with US-angiography was performed using MyLab Class-C (ESAOTE) with a linear probe BL433 (3-18MHz).
US examination protocol performed with a standard technique in longitudinal plane. SE examination results were represented in color over the conventional B-mode image using the standardized settings,
recommended by manufacturer.
The SE images were obtained using mild compression; based on the quality factor.
The SE images are composed of 256 degrees color map,
which is configured such that the soft tissue is shown in yellow,
green and red and the hard tissue in blue.
An ROI was selected in the repaired part of the Achilles tendon,
and quantitative data (SR index) were determined.
SE scans were repeated at least 4 times to obtain a mean value of the SR.
Sonoelastography Mean Strain Ratio values (SR1,
SR2 values) of the regenerated Achilles tendon were measured in the longitudinal plane predominantly in the repaired region during the follow-up period (1 week,
3,
6,
12,
36-40 weeks after surgery) in comparance to the fat tissue.
The total number od SE studies were 225.
Functional outcomes
Functional outcomes were assessed with the American Orthopedic Foot and Ankle Society (AOFAS) rating system [12].
Statisctical analysis
Student’s t-test were used to consider statistical significance with p<0.05.
Continuous variables are expressed as means±standard deviations (SD).
STATA software (version11.0; Stata Corp.,
TX) was used for data analysis.
General linear regression analysis and correlation coefficients were used to investigate the relationship between elasticity and functional scores.
Differences were considered statistically significant when P<0.05.