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Treatment Results After Acute Rupture of the Achilles Tendon.

This study is currently recruiting participants.
Verified January 2017 by Stale Bergman Myhrvold, University Hospital, Akershus
Sponsor:
ClinicalTrials.gov Identifier:
NCT01785264
First Posted: February 7, 2013
Last Update Posted: January 26, 2017
The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details.
Collaborators:
Oslo University Hospital
Sykehuset Ostfold
Vestre Viken Hospital Trust
Hjelp24
Information provided by (Responsible Party):
Stale Bergman Myhrvold, University Hospital, Akershus
January 28, 2013
February 7, 2013
January 26, 2017
February 2013
December 2017   (Final data collection date for primary outcome measure)
The defined endpoint is treatment results evaluated by the Achilles tendon Total Rupture Score (ATRS) at 12 month follow-up examination. [ Time Frame: The patients are examined at baseline and after 6 and 12 months. ]
The defined endpoint is treatment results evaluated by the Achilles tendon Total Rupture Score (ATRS). This is a patient-centered self-reporting instrument with good reliability, validity and sensitivity. Furthermore, ATRS will be combined with SF36, another commonly used self-reporting instrument. Pain is evaluated by a visual analogue scale (VAS). Functional results are evaluated by The MuscleLab measurement system (Ergotest Innovation, Porsgrunn, Norway). We will also measure dorsiflexion and plantarflexion range of movement (ROM) as well as the circumference of the calf, all widely used endpoints in similar studies.
Same as current
Complete list of historical versions of study NCT01785264 on ClinicalTrials.gov Archive Site
Risk of complications such as infections and reruptures within 12 months after initiation of treatment. [ Time Frame: The patients are examined at baseline and after 6 and 12 months. ]
Secondly, we want to compare the risk of complications such as infections and reruptures. The patients are examined at baseline and after 6 and 12 months. Since there are only minor functional improvements after 12 months, we do not plan any later follow-up as part of the main project. The 6 and 12 months examinations will be completed at the Norwegian Sport Medicine Clinic (NIMI), these examinations are blinded and performed by two physiotherapists who have not been taking part in the study prior to final follow-up. Patients will be wearing knee socks to hide potential scar tissue.
Same as current
SF36 after 12 months after initiation of treatment. [ Time Frame: Baseline, 6 and 12 months ]
ATRS will be combined with SF36, another commonly used self-reporting instrument. Pain is evaluated by a visual analogue scale (VAS). Functional results are evaluated by The MuscleLab measurement system (Ergotest Innovation, Porsgrunn, Norway). We will also measure dorsiflexion and plantarflexion range of movement (ROM) as well as the circumference of the calf, all widely used endpoints in similar studies.
Same as current
 
Treatment Results After Acute Rupture of the Achilles Tendon.
Non-operative Treatment of Acute Achilles Tendon Ruptures Versus Open and Mini-invasive Surgery: A Prospective Randomized Trial.
To compare the end-results of three different methods of treatment of acute achilles tendon ruptures, it is necessary to establish identical rehabilitation protocols. Traditionally, early mobilization has been reserved for patients treated surgically and this may have unintentionally skewed treatment results. The investigators have therefore designed a prospective randomized trial performed as collaboration between Akershus University Hospital (Ahus), Oslo University Hospital (The Emergency Department), Østfold Hospital (Fredrikstad) and Drammen Hospital. The four institutions were chosen because of their geographical proximity and because they jointly have a substantial catchment area. Treatment is divided into three arms, and patients between 18 and 60 years of age sustaining first time achilles tendon ruptures will be invited to participate.

Patients are randomized to either surgery or non-operative treatment. Surgery will be performed by open technique or by using a mini-invasive approach. Open surgery remains widespread and arguably the best documented treatment, however mini-invasive surgery is also included because of its potential to lessen the risk of wound complications. Michael Amlang and Hans Zwipp at the University of Dresden represent some of the leading foot- and ankle surgeons in Europe. They and their co-workers have developed a protocol for mini-invasive surgery using specially adapted proprietary instruments. Michael Amlang visited Ahus in 2012 teaching the general principles of the Dresden mini-invasive treatment. To ensure optimal and reproducible results, surgeons participating in the study must master both techniques.

All patients included in the study will be immobilized in equinus position for the first two weeks using a below-the-knee cast. Following the first two weeks the cast is replaced with a brace maintaining ∼12° plantar flexion (three heel lifts). We have chosen to use standardized heel lifts because it eases weightbearing compared to a hinged brace. After two weeks (four weeks from injury) the ankle position is adjusted to ∼8° plantar flexion (two heel lifts) and following additional two weeks the ankle position is adjusted to ∼4° plantar flexion (one heel lift). The last week of the orthosis treatment the heel lift is completely removed. Hence, the brace is retained for a total of six weeks, and patients are allowed full weight bearing as tolerated during the entire time period. The brace is worn day and night for the first two weeks, but is removed during nighttime for the last four weeks. Importantly, the immobilization regimen is identical for all three-treatment groups. To ensure identical rehabilitation following immobilization, physical therapy has to adhere to a standardized protocol supervised by an experienced physiotherapist at the Norwegian Sport Medicine Clinic (NIMI).

The defined endpoint is treatment results evaluated by the Achilles tendon Total Rupture Score (ATRS). This is a patient-centered self-reporting instrument with good reliability, validity and sensitivity. Furthermore, ATRS will be combined with SF36, another commonly used self-reporting instrument. Pain is evaluated by a visual analogue scale (VAS). Functional results are evaluated by The MuscleLab measurement system (Ergotest Innovation, Porsgrunn, Norway). The system consists of two different jump tests (drop counter-movement jump and hopping), two different strength tests (concentric heel rise and eccentric-concentric heel rise) and one muscular endurance test (standing heel rise) and the system has been shown to be both valid and reliable assessing lower leg function in patients with Achilles tendinopathy. We will also measure dorsiflexion and plantarflexion range of movement (ROM) as well as the circumference of the calf, all widely used endpoints in similar studies. Secondly, we want to compare the risk of complications such as infections and reruptures. The patients are examined at baseline and after 6 and 12 months. Since there are only minor functional improvements after 12 months, we do not plan any later follow-up as part of the main project. The 6 and 12 months examinations will be completed at the Norwegian Sport Medicine Clinic (NIMI), these examinations are blinded and performed by two physiotherapists who have not been taking part in the study prior to final follow-up. Patients will be wearing knee socks to hide potential scar tissue.

Although the minimum clinically important difference in ATRS score has yet to be determined, Carmont and coworkers have shown that 7 points represent the smallest detectable change. Moreover, a study by Metz et al. found that patients with reruptures of the achilles tendon presented on average 18 points lower scores whereas patients with injuries of the sural nerve or superficial wound infections presented scores 10 and 9 points lower than average, respectively. In order to detect a difference of 7 points in ATRS score with 80% power there must be 160 patients in each group. Power calculations are based on one-way ANOVA analyses assuming a common standard deviation of 20. This concomitantly allows us to detect differences as low as 8 % with respect to complications. This is of pivotal importance since assessing the risk of reruptures is essential when establishing treatment recommendations. We therefore plan to include a total of 530 patients allowing for expected loss during follow-up. Ahus, The Emergency Department of Oslo University Hospital, Drammen and Fredrikstad Hospitals have a catchment area of nearly 1.3 million people and treats in excess of 300 achilles tendon ruptures annually. This allows for completion of the inclusion period within three years. In our view, this is the first study to include a sufficient number of patients to detect lesser, but yet important differences, and the results will be published in a suitable international peer-reviewed journal.

The prospective randomized trial embodies many different disciplines and will spur off follow-up studies. As part of the main project we will conduct a treatment-cost analysis in relation to individual results. We will also perform an investigation based on ultrasound grading of Achilles tendon ruptures according to a classification system established by Michael Amlang and colleagues. Previous studies have provided evidence suggesting that treatment results may depend on the extension of the injury, and that treatment recommendations should be based on type of rupture sustained. This is of particular interest as it may facilitate individualized treatment. Together with the prospective randomized trial and the treatment-cost analysis, the ultrasound investigation will constitute the core of the Doctor of Philosophy (PhD) project.

Interventional
Not Provided
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary Purpose: Treatment
Rupture of Achilles Tendon
  • Procedure: Non-operative treatment
    All patients included in the study will be immobilized in equinus position for the first two weeks using a below-the-knee cast. Following the first two weeks the cast is replaced with a brace that will be used for additional six weeks during which the ankle angle will be adjusted from 3 heel-lifts to none. Patients randomized to non-operative treatment will have a cast applied within 3 days from injury.
  • Procedure: Open surgery
    All patients included in the study will be immobilized in equinus position for the first two weeks using a below-the-knee cast. Following the first two weeks the cast is replaced with a brace that will be used for additional six weeks during which the ankle angle will be adjusted from 3 heel-lifts to none.
  • Procedure: Mini-invasive surgery

    We will use the technique developed by Dr. Amlang and Professor Zwipp from Dresden, Germany. They have developed a protocol of mini-invasive surgery using specially adapted proprietary instruments.

    All patients included in the study will be immobilized in equinus position for the first two weeks using a below-the-knee cast. Following the first two weeks the cast is replaced with a brace that will be used for additional six weeks during which the ankle angle will be adjusted from 3 heel-lifts to none.

  • Active Comparator: Open surgery
    Treatment is divided into three arms, and patients between 18 and 60 years of age sustaining first time achilles tendon ruptures will be invited to participate. All three groups will have identical rehabilitation protocol. Open surgical repair is done through a 10 cm longitudinal incision, through the fascia curries and the paratenon. After necessary revision of the injure site, the tendons ends is sutured with a double layer, three knot, Krakow whip suture technique. 5 to 10 degrees of overcorrection compared to the uninjured side is endeavored. The paratenon is sewn as much as possible back over the injure site and suture material. The fascia is sutured and then continuous lying mattress skin suture.
    Interventions:
    • Procedure: Non-operative treatment
    • Procedure: Open surgery
    • Procedure: Mini-invasive surgery
  • Active Comparator: Non-operative treatment
    Non-operative treatment starts with casting the ankle in equinus position. The rest of the treatment from there on will be identical to the two other arms: Minimal invasive and open surgery. Casting lasts for 2 weeks for all three arms.
    Interventions:
    • Procedure: Non-operative treatment
    • Procedure: Open surgery
    • Procedure: Mini-invasive surgery
  • Active Comparator: Mini-invasive surgery
    Patients allocated to mini-invasive treatment will (as patients treated with open surgery) be operated within 7 days from injury with the technique developed by Dr Amlang and Prof Zwipp in Dresden. Patients in all three arms will have an active, early weight bearing rehabilitation protocol.
    Interventions:
    • Procedure: Non-operative treatment
    • Procedure: Open surgery
    • Procedure: Mini-invasive surgery
Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruiting
480
December 2018
December 2017   (Final data collection date for primary outcome measure)

Inclusion Criteria:

  • Patients between 18 and 60 years of age sustaining first time achilles tendon ruptures will be invited to participate.
  • The injury must be addressed with a below the knee cast in equinus position within 3 days from injury.
  • The operations must be carried out within 7 days from injury.

Exclusion Criteria:

  • Age below 18 or above 60 years
  • The use of quinolone antibiotics within 6 months prior to injury
  • Former achilles tendon injury on either side
  • Steroid injections close to the achilles tendon the last 6 months
  • The use of systemic steroids (prednisolon)
  • Diabetes mellitus
  • Dependent on walking aids
  • Not able to undergo the rehabilitation protocol
  • Not willing to perform the controls on the hospitals and examinations at NIMI
Sexes Eligible for Study: All
18 Years to 60 Years   (Adult)
Yes
Contact: Ståle B Myhrvold, MD +47 90915511 stalemyhrvold@gmail.com
Contact: Sigurd E Hoelsbrekken, MD PhD +47 41042274 s.e.hoelsbrekken@medisin.uio.no
Norway
 
 
NCT01785264
2012/530/REK
2013005 ( Other Identifier: The Norwegian Regional Health Authorities )
Yes
Not Provided
Plan to Share IPD: No
Stale Bergman Myhrvold, University Hospital, Akershus
University Hospital, Akershus
  • Oslo University Hospital
  • Sykehuset Ostfold
  • Vestre Viken Hospital Trust
  • Hjelp24
Principal Investigator: Ståle B Myhrvold, MD University Hospital, Akershus
Study Chair: Sigurd E Hoelsbrekken, PhD University Hospital, Akershus
University Hospital, Akershus
January 2017

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP