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

Knee Surg Sports Traumatol Arthrosc. 2018 Jul;26(7):2021-2029. doi: 10.1007/s00167-017-4621-8. Epub 2017 Jul 1.

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.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Achilles Tendon / surgery*
  • Adolescent
  • Adult
  • Aged
  • Casts, Surgical
  • Collagen Type I / biosynthesis*
  • Collagen Type I / metabolism
  • Female
  • Humans
  • Intermittent Pneumatic Compression Devices*
  • Male
  • Microdialysis
  • Middle Aged
  • Orthotic Devices
  • Patient Reported Outcome Measures
  • Peptide Fragments / metabolism*
  • Procollagen / metabolism*
  • Reconstructive Surgical Procedures / rehabilitation
  • Risk
  • Rupture / surgery*
  • Tendon Injuries / surgery*
  • Up-Regulation
  • Venous Thrombosis / prevention & control*
  • Wound Healing*
  • Young Adult

Substances

  • Collagen Type I
  • Peptide Fragments
  • Procollagen
  • procollagen Type I N-terminal peptide
  • procollagen Type III-N-terminal peptide