Purpose: The purpose of this randomised controlled trial was to compare outcomes of operative and non-operative management of Achilles tendon ruptures.

Method: Patients with acute complete Achilles tendon ruptures were randomised to receive open suture repair followed by graduated rehabilitation or graduated rehabilitation alone. The primary outcome measure was re-rupture rate. Assessments at three and six months, and one and two years included a modified Leppelhati score (no strength data), range of motion, calf circumference, and isokinetic strength at one and two years. We report the two year findings.

Results: Two centres randomized 145 patients (118 males and 27 females), mean age 40.9±8.8 years (22.5 – 67.2) to operative (n=73) and non-operative (n=72) treatment. Fourteen were lost to follow-up. Re-rupture occurred in three patients in both groups. The mean modified Lep-pelhati score (out of 85) was 78.2±7.7 in the operative group and 79.7±7.0 in the non-operative group, which was not significant (−1.5 95%CI −6.4 to 3.5, p=0.55). Mean side-to-side difference in plantar flexion and calf-circumference in the operative group was −2.0±3.2° and −1.4±1.2cm, and in the non-operative group −0.9±3.0°and −1.6±1.8cm respectively. Mean isokinetic plantar flexion strength was 62.4±24.2 for the operative and 56.7±19.3 for the non-operative group, which was not significant (5.7, 95%CI −3.1 to 14.5, p=0.20). There were a greater number of serious adverse events in the operative group, including pulmonary embolus in one patient, deep vein thrombosis in one and deep infections requiring irrigation and debridement in three.

Conclusion: This study suggests that non-operative management of Achilles tendon ruptures utilizing an accelerated rehabilitation programme may produce comparable results with fewer adverse events.

Purpose: Simultaneous high tibial osteotomy (HTO) and anterior cruciate ligament (ACL) reconstruction has been proposed as a treatment for patients with combined medial compartment knee osteoarthritis (OA) and ACL deficiency. Although goals of surgery are to correct malalignment, decrease knee joint load and enable continued participation in sports, few prospective studies evaluating these outcomes exist. Therefore, the objective of this study was to evaluate two-year changes in frontal plane alignment, dynamic knee joint load and self-reported function during sport after simultaneous HTO and ACL reconstruction.

Method: Thirty patients with varus alignment, medial compartment knee OA and ACL deficiency have undergone medial opening wedge HTO and hamstring tendon ACL reconstruction during a single operation. Full-length, standing AP radiographs (mechanical axis angle), dynamic knee joint loads (the peak external adduction moment about the knee during self-paced walking) and the Knee Injury and Osteoarthritis Outcome Scale (KOOS) were completed before and 24 months after surgery.

Results: Based on the 14 patients currently at 24.9 ± 1.67 months postop (12 males; age = 38.5 ± 7.5 yrs.; BMI = 29.5 ± 5.6, median Kellgren and Lawrence grade = 2), mechanical axis angle decreased significantly (p< 0.005) from −6.2 ± 3.63° to 0.29±1.94°. Despite a small (0.06 ± 0.10m/s), but significant (p< 0.05), increase in self-paced walking speed after surgery, the peak knee adduction moment decreased significantly (p < 0.001) from 2.96 ± 0.61 %BW*ht to 1.58 ± 0.48 %BW*ht [mean decrease = 1.38 %BW*ht (95% CI: 0.87 – 1.89)]. Each domain of the KOOS also improved significantly (p< 0.05), with the mean sports and recreation domain increasing (p=0.001) from 26.92 ± 24.29 to 66.54 ± 28.09 [mean increase = 39.62 (95% CI: 20.09 – 51.14)]. Data from 30 patients will be available at time of presentation.

Conclusion: Two-year outcomes after simultaneous medial opening wedge HTO and ACL reconstruction suggest this treatment results in substantial improvements in alignment, knee joint load and self-reported functioning during sport.

Previous research suggests knee joint moments and muscle activity during walking are altered in patients with anterior cruciate ligament (ACL) deficiency and in patients with medial compartment knee osteoarthritis (OA). The objective of this study was to compare knee joint flexion and adduction moments and the extent of quadriceps-hamstring muscle co-contraction before and one year after combined simultaneous ACL reconstruction and high tibial osteotomy (HTO).

Eighteen patients (three females, fifteen males; age = 40 ± 8 yrs.; BMI = 28.8 ± 5.77) with ACL deficiency and OA affecting primarily the medial compartment of the knee underwent ACL reconstruction (hamstring autograft) and medial opening wedge HTO procedures during a single operation. All patients completed pre-operative and one-year postoperative quantitative gait assessments. Three-dimensional kinetic and kinematic data were collected during self-paced walking and used to calculate the peak external flexion and adduction moments about the knee. Electromyographic (EMG) activity was collected from the hamstrings and quadriceps and used to calculate the co-contraction ratio. Peak moments and co-contraction ratios were compared pre and postoperatively using paired t-tests.

The peak knee flexion moment decreased from 2.31 ± 1.14 to 1.33 ± 0.73 %BW*ht (p=0.001); mean decrease = 0.98 %BW*ht (95%CI: 0.49–1.47). The peak knee adduction moment decreased from 2.81 ± 0.62 to 1.69 ± 0.61 %BW*ht (p< 0.001); mean decrease = 1.12 %BW*ht (95% CI: 0.80–1.43). The quadriceps-hamstring co-contraction ratio decreased from 0.82 ± 0.14 to 0.72 ± 0.18 (p=0.056); mean decrease = 0.10 (95% CI: −0.003 – 0.21).

The present findings suggest that combined simultaneous ACL reconstruction and HTO significantly decreases knee flexion and adduction moments during walking. Although the present findings suggest that the quadriceps-hamstring co-contraction ratio also decreases, future research with more patients is required to confidently evaluate potential changes in muscle activity. These findings are consistent with an overall reduction in dynamic knee joint load.