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Knee Surg Sports Traumatol Arthrosc. 2018 Jul;26(7):2011-2020. doi: 10.1007/s00167-017-4606-7. Epub 2017 Jun 21.

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

Author information

1
Integrative Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
2
Department of Orhopaedics, Institute of Clinical Sciences at Sahlgrenska Acadamy, University of Gothenburg, Gothenburg, Sweden.
3
Sahlgrenska University Hospital, Mölndal, Sweden.
4
Department of Psychiatry, Tiohundra AB, Norrtälje, Sweden.
5
Hallands Sjukhus, Kungsbacka, Sweden.
6
Department of Orthopaedic Surgery, The Princess Royal Hospital, Telford, Shropshire, UK.
7
Integrative Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. paul.ackermann@karolinska.se.
8
Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden. paul.ackermann@karolinska.se.

Abstract

PURPOSE:

The 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.

METHODS:

Observational 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.

RESULTS:

Patients 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.

CONCLUSION:

The 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 EVIDENCE:

II.

KEYWORDS:

Achilles tendon; Glutamate; Glycerol; Microdialysis; Operative time; Pain; Patient-reported outcomes; Physical activity; Post-operative complications; Rupture

PMID:
28638971
PMCID:
PMC6061452
DOI:
10.1007/s00167-017-4606-7
[Indexed for MEDLINE]
Free PMC Article

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