Michael R. Carmont’s research while affiliated with University of Gothenburg and other places

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Publications (144)


Distribution of patients treated with surgery (left) and nonsurgical treatments (right) reporting fear and no fear of Achilles tendon reinjury. Pearson's χ² test.
Distribution of women (left) and men (right) reporting fear and no fear of Achilles tendon reinjury. Pearson's χ² test.
Proportion of patients reporting fear of Achilles tendon reinjury within each age category. The percentages reporting yes/no sum up to 100% in each age category. A χ² test for association indicates an association between fear and age categories (p = 0.008).
Fear of reinjury after acute Achilles tendon rupture is related to poorer recovery and lower physical activity postinjury
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October 2024

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27 Reads

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Agnes LeGreves

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Purpose The aim of this study was to investigate how fear of reinjury to the Achilles tendon affects return to previous levels of physical activity and self‐reported Achilles tendon Total Rupture Score (ATRS) outcomes. Methods Data were collected from a large cohort of patients treated for an acute Achilles tendon rupture at Sahlgrenska University Hospital Mölndal between 2015 and 2020. The ATRS and additional questions concerning fear of reinjury, treatment modality, satisfaction of treatment and recovery were analyzed 1–6 years postinjury. Analysis was performed to determine the impact of fear of reinjury on patient‐reported recovery and physical activity. Results Of a total of 856 eligible patients, 550 (64%) answered the self‐reported questionnaire and participated in the follow‐up. Of the participants, 425 (77%) were men and 125 (23%) were women. ATRS, recovery in percentage, satisfaction of treatment, recovery on a 5‐point scale and physical activity level post‐ versus preinjury were significantly related to fear of reinjury (p < 0.001). Of the nonsurgically treated patients, 59% reported fear of reinjury compared to 48% of the surgically treated patients (p = 0.024) Patients that reported fear of reinjury had a 15‐point lower median ATRS score than those who did not (p < 0.001). Conclusion More than half of patients who have suffered an Achilles tendon rupture are afraid of reinjuring their tendon. Patients who reported fear of reinjury exhibited a significantly lower ATRS score. This indicates the importance of addressing psychological aspects in the treatment after this injury. Level of Evidence Level II.

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The option of transosseous distal suture placement during minimally invasive Achilles tendon repair for high-risk patients can improve outcomes, however does not prevent re-rupture

August 2024

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87 Reads

Purpose Achilles tendon ruptures (ATRs) close to the insertion, in high-level athletes, and in patients at high risk of re-rupture, may be better suited to operative repair. Minimally Invasive Repair (MIR) of the Achilles tendon has excellent outcome and low complication rates. Traditionally MIR has showed lower repair strength, failing due to suture pull-out from the distal tendon stump. The aim of this study was to describe the outcome of ATR patients who received transosseous distal suture placement using a standard technique as a reference. Methods Following ATR, patients were evaluated for pre-injury activity level, body weight, location of the tear and size of the distal Achilles tendon stump. Patients considered to be at high-risk of re-rupture: Tegner level ≥ 8, body weight ≥ 105Kg and distal ATR, received transosseous (TO) distal suture placement (n = 20) rather than the usual transtendinous (TT) technique (n = 55). Patient reported outcome measures and functional evaluation was performed at 12 months following repair. Results At 12 months follow up both methods resulted in good median (IQR) Achilles tendon Total Rupture Score TO 83.8 (74-88.3) vs. TT 90 (79–94), low increased relative Achilles Tendon Resting Angle TO -3.5˚ (3.6) vs. TT -3.5˚ (3.3) and mean (SD) Single leg Heel-Rise Height Index TO 88.2% (9.9) vs. TT 85.6% (9.9) (n.s.). There were 4 re-ruptures in the high-risk group and 2 in the group receiving TT distal suture placement. All but one of these were traumatic in nature. The mode of failure following TO distal suture placement was proximal suture pull out. Conclusions To distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients can lead to results equivalent to those in lower-risk patients treated with a standard TT MIR technique, except for the re-rupture rate which remained higher. There may be factors that have greater influence on outcome other than suture placement following ATR.


PRISMA-flowchart for the inclusion of studies, The PRISMA 2020 statement [54]
Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures - a systematic review

December 2023

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66 Reads

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1 Citation

Introduction A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft. Methods A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized Studies (MINORS). Results Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2–13) for all studies. Conclusion Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult. Level of evidence Level IV.




Table 1
Demographic characteristics and mechanism of re-rupture following MIR prior to 2016.
The option of transosseous distal suture placement during minimally invasive Achilles tendon repair for high-risk patients can improve outcomes, however does not prevent re-rupture

November 2023

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34 Reads

Purpose: Achilles tendon ruptures (ATRs) close to the insertion, in high-level athletes, and in patients at high risk of re-rupture, may be better suited to operative repair. Minimally Invasive Repair (MIR) of the Achilles tendon has excellent outcome and low complication rates. Traditionally MIR has showed lower repair strength, failing due to suture pull-out from the distal tendon stump. The aim of this study was to describe the outcome of ATR patients who received transosseous distal suture placement using a standard technique as a reference. Methods: Following ATR, patients were evaluated for pre-injury activity level, body weight, location of the tear and size of the distal Achilles tendon stump. Patients considered to be at high-risk of re-rupture: Tegner level ≥8, body weight ≥105Kg and distal ATR, received transosseous (TO) distal suture placement (n=20) rather than the usual transtendinous (TT) technique (n=55). Patient reported outcome measures and functional evaluation was performed at 12 months following repair. Results: At 12 months follow up both methods resulted in good median (IQR) Achilles tendon Total Rupture Score TO 83.8 (74-88.3) vs. TT 90 (79-94), low increased relative Achilles Tendon Resting Angle TO -3.5˚ (3.6) vs. TT -3.5˚ (3.3) and mean (SD) Single leg Heel-Rise Height Index TO 88.2% (9.9) vs. TT 85.6% (9.9) (n.s.). There were 4 re-ruptures in the high-risk group and 2 in the group receiving TT distal suture placement. All but one of these were traumatic in nature. The mode of failure following TO distal suture placement was proximal suture pull out. Conclusions: The option of TO distal suture placement during minimally invasive Achilles tendon repair for high-risk patients can improve outcomes, however this technique did not prevent re-rupture. There may be factors that have greater influence on outcome other than suture placement following ATR.




Evaluation of the Achilles Tendon

June 2023

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81 Reads

The Achilles tendon often withstands extensive power and is commonly subject to acute ruptures and chronic overuse pathologies. The incidence of Achilles tendon ruptures and Achilles tendinopathy is increasing, and a thorough clinical examination is essential in establishing the diagnosis. To fully recover from Achilles tendon rupture and Achilles tendinopathy, a well-planned rehabilitation programme is necessary. An early diagnosis can therefore help the patient to recover from injury more rapidly. Basic knowledge on the anatomy of the lower leg and a well-executed clinical examination are necessary to establish the diagnosis.The clinical examination of the Achilles tendon consists of inspection and palpation of the Achilles tendon and surrounding tissues. Another part of the examination is passive and active plantar flexion of the foot. For acute injuries and Achilles tendon ruptures, the calf squeeze test and Matles’ test are well acknowledged and useful. The corresponding tests that may be used for chronic overuse syndromes are the “painful arc sign” and the Royal London Hospital test. Even though the clinical examination is considered sufficient, plain radiographs, ultrasonography, and MRI can be of help to establish the diagnosis and deciding on further management of the Achilles tendon injury.There are several patient-reported outcome measurements (PROMs) used in Achilles tendon injury management and rehabilitation. The Achilles tendon total rupture score (ATRS) is commonly used for Achilles tendon ruptures and the Victorian Institute of Sports Assessment-Achilles (VISA-A) for Achilles tendinopathy.KeywordsAchilles tendonAchilles tendon ruptureAchilles tendinopathyClinical evaluationCalf squeeze testMatles’ testATRAPainful arc signRoyal London Hospital testATRSVISA-A


Citations (57)


... The anatomic myotendinous junction is considered the zone of transition from the soleus to the Achilles tendon proper distally (as it combines with the aponeurosis of the two heads of the gastrocnemius) [11,12]. The proportion of Achilles tendon ruptures occurring at the MTJ is unclear; however, one retrospective study that examined over 500 Achilles tendon rupture patients found that 6.7% of patients had a tear at the MTJ [13]. These MTJ Achilles tendon injuries have been reported to have increased calf swelling due to bleeding from the muscular portion of the tear [10], and are generally more difficult to diagnose clinically than their mid-substance counterparts. ...

Reference:

Outcomes of operative and nonoperative management of myotendinous Achilles tendon ruptures: a systematic review
Musculotendinous ruptures of the achilles tendon had greater heel-rise height index compared with mid-substance rupture with non-operative management: A retrospective cohort study
  • Citing Article
  • December 2023

Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine

... No studies, as far as we know, have reported the surgical treatment of chronic Achilles tendon rupture in a patient with AKU. Although many surgical procedures for the surgical treatment of chronic Achilles tendon rupture have been reported [11][12][13][14]20], to date, no single procedure has been shown to be superior to others. The selection of surgical technique is generally based on the location of the tear, the size of the gap between the tendon stumps, patient characteristics, and the surgeon's preference. ...

Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures - a systematic review

... Since 2020, the National Health Service (NHS) has faced significant challenges in managing patient load post pandemic, including those with musculoskeletal injuries such as ATR. This may be attributed to various factors such as altered working environments and delayed access to healthcare services due to pandemicrelated disruptions [15]. This increased demand for healthcare services, coupled with the backlog of musculoskeletal cases, highlights the urgent need for innovative solutions to alleviate the burden on NHS hospitals. ...

The influence of the COVID pandemic on the epidemiology of Achilles tendon ruptures in east Shropshire, United Kingdom
  • Citing Article
  • November 2022

Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine

... Regardless of the initial treatment strategy of operative or nonoperative care, some individuals regain more symmetrical side-to-side function, while others remain with pronounced deficits [1]. In addition to patient age [3], literature suggests that ultrasound imaging of the Achilles tendon (AT) and plantarflexor muscle structural characteristics may have a relevant role in predicting functional outcome [4][5][6]. For instance, early measurement of AT crosssectional area (CSA) [4][5][6] and ultrasound elastography-based tendon stiffness may be associated with functional performance [4,7]. ...

Sex differences in patients’ recovery following an acute Achilles tendon rupture – a large cohort study

... In comparison, they found that five patients with midsubstance Achilles tendon ruptures unfortunately experienced tendon elongation. Tendon elongation can significantly impact a patient's plantarflexion power and overall satisfaction [34,35]. All patients in the myotendinous group were able to do a single-leg heel raise and had on average 79% the heel-raise ability (HRHI) compared to their contralateral side. ...

Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms

Knee Surgery Sports Traumatology Arthroscopy

... Three patients (7.1%) developed postoperative wound complications, including superficial skin necrosis in two cases. Interestingly, Niklas et al. 29 proposed an endoscopically assisted longitudinal calcaneal screw fixation for Achilles tendon reconstruction. At 12-months postoperative follow-up, patients had a median ATRS of 76 (45-99). ...

Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques

Knee Surgery Sports Traumatology Arthroscopy

... They are defined as the most common as patellar tendinopathies and iliotibial band strains. [12] [16] In the retrospective and prospective analysis in the Zwingenberger study, injuries were divided according to their location in the body. The majority of injuries in participants occurred while running (50%), followed by cycling (43%) and swimming (7%). ...

A Systematic Review of Long‐Distance Triathlon Musculoskeletal Injuries

... Following Tendoachilles (TA) injury repair, postoperative peritendinous adhesions, whether deep or superficial, may develop (1) . TA adhesions impair tendon mobility and gliding, which results in ankle stiffness and adversely affects the outcome of surgical repair. ...

The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture

Knee Surgery Sports Traumatology Arthroscopy

... The surgery was performed under spinal or general anaesthesia using a tourniquet. The patient was placed in a semiprone position to allow easier access to both the semitendinosus graft and the ruptured Achilles tendon [5]. With the knee flexed to 90˚ a 2-cm longitudinal incision was made over the pes anserinus and the semitendinosus tendon was identified and harvested. ...

Endoscopically Assisted Reconstruction of the Achilles Tendon Using Semitendinosus Graft

Video Journal of Sports Medicine

... A RCT with 27 subjects receiving PRP injections demonstrated positive effects in chronic Achilles tendinopathy [57]. However, a larger RCT involving 240 subjects with chronic midportion Achilles tendinopathy did not reveal any significant effect of PRP therapy compared to sham therapy [58]. ...

Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy: A Randomized Clinical Trial

JAMA The Journal of the American Medical Association