Skip to main content
SpringerLink
Log in

Diabetes and treatment with orally administrated corticosteroids negatively affect treatment outcome at follow-up after acute Achilles tendon rupture

  • ANKLE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Studies investigating the influence of comorbidities on patient-reported outcomes after acute Achilles tendon ruptures (ATR) are lacking. In this study, the aim was to investigate the effect of comorbidity and medical treatment on the patient-reported outcome measure Achilles tendon total rupture score (ATRS).

Methods

The study was performed as a registry study from the Danish Achilles tendon Database (DADB). In the DADB, ATRS was registered at baseline (prior to rupture), at 3–6 month, 1-year and 2-year follow-ups. The outcomes were ATRS at follow-up and the change in ATRS from baseline to follow-up. Variables of interest were diabetes, hypertension, rheumatic disease and treatment with orally administrated corticosteroids. Linear mixed-effects models including all follow-up time points in the same model were used adjusting for sex, age group, treatment (operative or non-operative) and the investigated comorbidities.

Results

Data were collected from 2012 to 2019. Two thousand and four patients with ATR were included. Patients with the investigated comorbidities and treatment with orally administrated corticosteroid scored 10.6–19.1 points lower in mean ATRS at baseline (prior to rupture) compared to patients without the respective disease or treatment. At follow-up, patients with diabetes (mean difference, [95% CI]) (− 6.2, [− 11.7; − 0.8]; P = 0.03) and patients in treatment with orally administrated corticosteroids (− 10.9, [− 16.2; − 5.7]; P < 0.01) had a statistically significantly worse ATRS than patients without the respective disease. However, change in ATRS from baseline to follow-up was not affected. Hypertension and rheumatic disease did not affect ATRS at follow-up but had a positive effect on change in ATRS (4.3, [0.5; 8.1]; P = 0.03) and (12.0, [5.0; 19.9]; P < 0.01), respectively. No other statistically significant differences were found.

Conclusion

This study showed that patients with diabetes, hypertension, rheumatic disease and patients in treatment with orally administrated corticosteroids had a lower ATRS at baseline (prior to the rupture) when compared to patients without the respective disease or treatment. Diabetes and treatment with orally administrated corticosteroids did negatively affect ATRS at follow-up, but none of the investigated comorbidities or treatment with orally administrated corticosteroids did negatively affect change in ATRS from baseline to follow-up.

Level of evidence

Level III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

ATR:

Acute Achilles tendon rupture

ATRS:

Achille tendon total rupture score

DADB:

Danish Achilles tendon Database

BMI:

Body mass index

SD:

Standard deviation

IQR:

Inter quartile range

CI:

Confidence interval

References

  1. Abate M, Salini V, Antinolfi P, Schiavone C (2014) Ultrasound morphology of the Achilles in asymptomatic patients with and without diabetes. Foot Ankle Int 35:44–49

    Article  Google Scholar 

  2. Amlang MH, Zwipp H, Friedrich A, Peaden A, Bunk A, Rammelt S (2011) Ultrasonographic classification of Achilles tendon ruptures as a rationale for individual treatment selection. ISRN Orthop. https://doi.org/10.5402/2011/869703

    Article  PubMed  PubMed Central  Google Scholar 

  3. Aujla R, Patel S, Jones A, Bhatia M (2018) Predictors of functional outcome in non-operatively managed Achilles tendon ruptures. Foot Ankle Surg 24:336–341

    Article  Google Scholar 

  4. Barfod KW, Hansen MS, Holmich P, Troelsen A, Kristensen MT (2016) Efficacy of early controlled motion of the ankle compared with no motion after non-operative treatment of an acute Achilles tendon rupture: study protocol for a randomized controlled trial. Trials 17:564

    Article  Google Scholar 

  5. Bruggeman NB, Turner NS, Dahm DL, Voll AE, Hoskin TL, Jacofsky DJ, Haidukewych GJ (2004) Wound complications after open Achilles tendon repair: an analysis of risk factors. Clin Orthop Relat Res. https://doi.org/10.1097/01.blo.0000144475.05543.e7

    Article  PubMed  Google Scholar 

  6. Carmont MR, Zellers JA, Brorsson A, Nilsson-Helander K, Karlsson J, Grävare Silbernagel K (2020) Age and tightness of repair are predictors of heel-rise height after Achilles tendon rupture. Orthop J Sport Med 8:2325967120909556

    Article  Google Scholar 

  7. Cramer A, Hansen MS, Sandholdt H, Jones PK, Christensen M, Jensen SML, Hölmich P, Barfod KW (2019) Completeness and data validity in the Danish Achilles tendon Database. Dan Med J 66:A5548

    PubMed  Google Scholar 

  8. Cramer A, Jacobsen NC, Hansen MS, Sandholdt H, Hölmich P, Barfod KW (2020) Outcome after acute Achilles tendon rupture is not negatively affected by female sex and age over 65 years. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-06003-7

    Article  PubMed  Google Scholar 

  9. Dombrowski M, Murawski CD, Yasui Y, Chen AF, Ewalefo SO, Fourman MS, Kennedy JG, Hogan MV (2019) Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc 27:2840–2851

    Article  Google Scholar 

  10. Egemen O, Ozkaya O, Ozturk M, Sen E, Akan M, Sakiz D, Aygit C (2016) The biomechanical and histological effects of diabetes on tendon healing: experimental study in rats. J Hand Microsurg 04:60–64

    Article  Google Scholar 

  11. Erickson BJ, Mascarenhas R, Saltzman BM, Walton D, Lee S, Cole BJ, Bach BR (2015) Is operative treatment of achilles tendon ruptures superior to nonoperative treatment?: a systematic review of overlapping meta-analyses. Orthop J Sport Med 3:2325967115579188

    Google Scholar 

  12. Ganestam A, Barfod K, Klit J, Troelsen A (2013) Validity and reliability of the Achilles tendon total rupture score. J Foot Ankle Surg 52:736–739

    Article  Google Scholar 

  13. Ganestam A, Kallemose T, Troelsen A, Barfod KW (2016) Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients. Knee Surg Sports Traumatol Arthrosc 24:3730–3737

    Article  Google Scholar 

  14. Hansen MS, Nilsson Helander K, Karlsson J, Barfod KW (2020) Performance of the Achilles tendon total rupture score over time in a large national database: development of an instruction manual for accurate use. Am J Sports Med 48:1423–1429

    Article  Google Scholar 

  15. Hansen MS, Vestermark MT, Hölmich P, Kristensen MT, Barfod KW (2020) Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial. Trials NLM 21:399

    Article  Google Scholar 

  16. Hillam JS, Mohile N, Smyth N, Kaplan J, Aiyer A (2019) The effect of obesity on Achilles rupture repair. Foot Ankle Spec 12:503–512

    Article  Google Scholar 

  17. Holmes GB, Lin J (2006) Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int 27:952–959

    Article  Google Scholar 

  18. Hutchison AM, Topliss C, Beard D, Evans RM, Williams P (2015) The treatment of a rupture of the Achilles tendon using a dedicated management programme. Bone Jt J 97-B:510–515

    Article  CAS  Google Scholar 

  19. Huttunen TT, Kannus P, Rolf C, Fellander-Tsai L, Mattila VM (2014) Acute Achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012. Am J Sports Med 42:2419–2423

    Article  Google Scholar 

  20. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J (2016) A prospective randomized trial comparing surgical and nonsurgical treatments of acute Achilles tendon ruptures. Am J Sports Med 44:2406–2414

    Article  Google Scholar 

  21. Nilsson-Helander K, Silbernagel KG, Thomee R, Faxen E, Olsson N, Eriksson BI, Karlsson J (2010) Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med 38:2186–2193

    Article  Google Scholar 

  22. Nilsson-Helander K, Thomee R, Silbernagel KG, Thomee P, Faxen E, Eriksson BI, Karlsson J (2007) The Achilles tendon total rupture score (ATRS): development and validation. Am J Sports Med 35:421–426

    Article  Google Scholar 

  23. Ochen Y, Beks RB, Van Heijl M, Hietbrink F, Leenen LPH, Van Der Velde D, Heng M, Van Der Meijden O, Groenwold RHH, Houwert RM (2019) Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ 7(364):k5120

    Article  Google Scholar 

  24. Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Thomee R, Faxen E, Silbernagel KG (2011) Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 19:1385–1393

    Article  Google Scholar 

  25. Olsson N, Petzold M, Brorsson A, Karlsson J, Eriksson BI, Silbernagel KG (2014) Predictors of clinical outcome after acute Achilles tendon ruptures. Am J Sports Med 42:1448–1455

    Article  Google Scholar 

  26. Olsson N, Silbernagel KG, Eriksson BI, Sansone M, Brorsson A, Nilsson-Helander K, Karlsson J (2013) Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures. Am J Sports Med 41:2867–2876

    Article  Google Scholar 

  27. Silbernagel KG, Brorsson A, Olsson N, Eriksson BI, Karlsson J, Nilsson-Helander K (2015) Sex differences in outcome after an acute Achilles tendon rupture. Orthop J Sport Med 3:2325967115586768

    Google Scholar 

  28. Taguchi T, Kubota M, Saito M, Hattori H, Kimura T, Marumo K (2016) Quantitative and qualitative change of collagen of Achilles tendons in rats with systemic administration of glucocorticoids. Foot Ankle Int 37:327–333

    Article  Google Scholar 

  29. Westin O, Svensson M, Nilsson Helander K, Samuelsson K, Gravare Silbernagel K, Olsson N, Karlsson J, Hansson Olofsson E (2018) Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 26:3074–3082

    Article  Google Scholar 

  30. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A (2010) Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Jt Surg Am 92:2767–2775

    Article  Google Scholar 

Download references

Acknowledgements

We would like to thank the following hospitals in Denmark that have contributed data to the Danish Achilles tendon Database; Aalborg Hospital, Køge Hospital, Nykøbing Falster Hospital, Amager-Hvidovre Hospital, Kolding Hospital, Vendsyssel Hospital, Hjørring Hospital, Thy-Mors Hospital, Himmerland Farsø Hospital, Viborg Regional Hospital, Randers Regional Hospital and Slagelse Hospital.

Funding

No funds were received.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Copenhagen University Hospital, Kettegård Allé 30, Amager-Hvidovre, 2650, Hvidovre, Denmark

    Allan Cramer, Nanna Cecilie Jacobsen, Maria Swennergren Hansen, Per Hölmich & Kristoffer Weisskirchner Barfod

  2. Department of Physiotherapy, Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark

    Maria Swennergren Hansen

  3. Clinical Research Center, Copenhagen University Hospital, Hvidovre, Denmark

    Håkon Sandholdt

Authors
  1. Allan Cramer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nanna Cecilie Jacobsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Maria Swennergren Hansen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Håkon Sandholdt
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Per Hölmich
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kristoffer Weisskirchner Barfod
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The authors (AC, NCJ, MSH, HS, PH, KWB) designed the study and interpreted the data. AC, HS and KWB made the statistical analysis. AC and KWB wrote the first version of the manuscript. All authors have critically revised the manuscript and have approved the final version.

Corresponding author

Correspondence to Allan Cramer.

Ethics declarations

Conflict of interest

KWB is paid consultant for DJO Nordic. The rest of the authors declare that they have no conflict of interests.

Ethical approval

Institutional review board (IRB) approval was given by the Ethical Review Board of the Capital Region of Denmark April 23 2020, registration no. H-20028216. Approval from the Danish Data Protection Agency of the Capital Region of Denmark was given March 11 2020, registration no. P-2020-238.

Informed consent

Informed consent was obtained from all study participants.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cramer, A., Jacobsen, N.C., Hansen, M.S. et al. Diabetes and treatment with orally administrated corticosteroids negatively affect treatment outcome at follow-up after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 29, 1584–1592 (2021). https://doi.org/10.1007/s00167-020-06371-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-020-06371-0

Keywords

Search

Navigation