Achilles tendon rupture healing is enhanced by intermittent pneumatic compression upregulating collagen type I synthesis

Md Abdul Alim, Erica Domeij-Arverud, Gunnar Nilsson, Gunnar Edman, Paul W Ackermann, Md Abdul Alim, Erica Domeij-Arverud, Gunnar Nilsson, Gunnar Edman, Paul W Ackermann

Abstract

Purpose and hypothesis: Adjuvant intermittent pneumatic compression (IPC) during leg immobilization following Achilles tendon rupture (ATR) has been shown to reduce the risk of deep venous thrombosis. The purpose of this study was to investigate whether IPC can also promote tendon healing.

Methods: One hundred and fifty patients with surgical repair of acute ATR were post-operatively leg immobilized and prospectively randomized. Patients were allocated for 2 weeks of either adjuvant IPC treatment (n = 74) or treatment-as-usual (n = 74) in a plaster cast without IPC. The IPC group received 6 h daily bilateral calf IPC applied under an orthosis on the injured side. At 2 weeks post-operatively, tendon healing was assessed using microdialysis followed by enzymatic quantification of tendon callus production, procollagen type I (PINP) and type III (PIIINP) N-terminal propeptide, and total protein content. 14 IPC and 19 cast patients (control group) consented to undergo microdialysis. During weeks 3-6, all subjects were leg-immobilized in an orthosis without IPC. At 3 and 12 months, patient-reported outcome was assessed using reliable questionnaires (ATRS and EQ-5D). At 12 months, functional outcome was measured using the validated heel-rise test.

Results: At 2 weeks post-rupture, the IPC-treated patients exhibited 69% higher levels of PINP in the ruptured Achilles tendon (AT) compared to the control group (p = 0.001). Interestingly, the IPC-treated contralateral, intact AT also demonstrated 49% higher concentrations of PINP compared to the non-treated intact AT of the plaster cast group (p = 0.002). There were no adverse events observed associated with IPC. At 3 and 12 months, no significant (n.s.) differences between the two treatments were observed using patient-reported and functional outcome measures.

Conclusions: Adjuvant IPC during limb immobilization in patients with ATR seems to effectively enhance the early healing response by upregulation of collagen type I synthesis, without any adverse effects. Whether prolonged IPC application during the whole immobilization period can also lead to improved long-term clinical healing response should be further investigated. The healing process during leg immobilization in patients with Achilles tendon rupture can be improved through adjuvant IPC therapy, which additionally prevents deep venous thrombosis.

Level of evidence: Randomized controlled trial, Level I.

Keywords: Achilles tendon rupture; Intermittent pneumatic compression devices; Microdialysis; Procollagen; Regeneration.

Conflict of interest statement

Conflict of interest

Paul W Ackermann declares that he has received Grants for this study.

Funding

This study was supported by the by the regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institutet (Project No. SLL20100168), the Swedish National Centre for Sports Research, Swedish Research Council (Project No. 2012-3510) and by a Grant provided by DJO, Vista, California.

Ethical approval

Ethical approval was obtained from the Regional Ethical Review Board, Stockholm (IRB registration number 2009/2079-31/2).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Figures

Fig. 1
Fig. 1
CONSORT study flow diagram. Patients with ATR were randomized to either adjuvant IPC (n = 74) or treatment-as-usual in a plaster cast without IPC (n = 74) for the first 2 weeks after ATR surgical repair. At 2 weeks, the intervention with IPC stopped, and subsequently all patients were treated with the same protocol for rehabilitation
Fig. 2
Fig. 2
Callus production without and with IPC. Concentration of markers of callus production, a procollagen type I (PINP), b procollagen type III (PIIINP), and c total protein content, in the IPC-treated tendons versus the tendons without IPC treatment. Callus production is assessed in both the healing, i.e. ruptured Achilles tendons (n = 14 IPC, n = 19 no IPC) and the contralateral intact Achilles tendons (n = 14 IPC, n = 18 no IPC). Data are expressed as mean ± SEM. ** p < 0.01, *** p < 0.0001

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