Acute rupture of the Achilles tendon

The Achillon achilles tendon repair: is it strong enough?

BACKGROUND

Open repair of the Achilles tendon is associated with wound breakdown, infection and percutaneous methods risk sural nerve injury. The Achillon mini-incision technique can reduce these risks and may provide the opportunity for early active rehabilitation. The aim of this study was to compare the strength of the Achillon method with the commonly used Kessler method and to assess whether the strength of the repair was related to tendon diameter.

MATERIALS AND METHODS

Simulated ruptures in sheep Achilles tendons were repaired using either the Achillon method or a two-strand Kessler technique with a No. 2 Ticron suture (Tyco Healthcare, UK). Each tendon diameter was measured, and matched for both groups. Specimens were loaded to failure using an Instron tensile testing machine (Instron Limited, UK).

RESULTS

Mean load to failure for the Achillon repair was 153 N+/-60 (range, 65 to 270), and the mean load to failure for the Kessler Repair was 123 N+/-24 (range, 75 to 150). This difference was not statistically significant (p=0.21). There was a statistically significant higher mean load to failure for wider tendons repaired by the Achillon method (p=0.05), however mean load to failure was not related to tendon width in Kessler repairs (p=0.23).

CONCLUSION

This is the first study to compare these two methods of repair. The Achillon repair has comparable tensile strength to the Kessler Repair.

CLINICAL RELEVANCE

The Achillon repair appears to be a biomechanically sound method of repair for the acutely ruptured Achilles tendon.

Management of acute Achilles tendon ruptures in the United Kingdom

PURPOSE

To survey the management of acute Achilles tendon ruptures in the United Kingdom.

METHODS

A questionnaire with 4 different Achilles tendon rupture scenarios affecting patients of different ages and activity levels was sent to orthopaedic consultants specialised in sports trauma, foot and ankle surgery. Their treatment methods including surgical techniques, immobilisation and rehabilitation regimens were surveyed.

RESULTS

The response rate was 22% (51/231). Among the 51 respondents, 25 had managed less than 6 such patients in the preceding year. 26 (51%) used clinical examination (e.g. calf squeeze test) to make the diagnosis, 16 (31%) used ultrasonography, and 4 (8%) used magnetic resonance imaging. Surgical management was preferred for younger and more functionally demanding individuals. Open repairs were used more often than percutaneous repairs (72 vs 19%). Across the 4 scenarios, the mean time to return to full activity was 17 (range, 12-32) weeks for conservative to 19 (range, 10-40) weeks for surgical management.

CONCLUSION

Variation in opinion among respondents was wide. Randomised controlled trials are needed to assess optimal treatment.

Repair of experimental Achilles tenotomy with porcine renal capsule material in a rat model

Porcine small intestinal submucosa (SIS) is a collagenous acellular matrix which has found substantial utility as a tissue growth scaffold. In the present study, the utility of porcine renal capsule matrix (RCM) was compared to SIS in a rat Achilles tenotomy repair model. Groups of rats underwent surgical tenotomy followed by either no repair, repair with a SIS graft, or repair with a RCM graft. The weight-bearing ability of the manipulated limb was evaluated for 10 days following surgery using a subjective scale. Tenotomy sites sampled 28 days after surgery were numerically graded for degree of histologic change. There were no statistically significant differences between groups with respect to return to weight-bearing ability (p >or= 0.05) or degree of histologic change (p >or= 0.001); however, a non-significant trend suggested that rats treated with SIS or RCM experienced a faster return to limb function than untreated rats, and RCM-treated rats had slightly higher scores for degree of histologic change, suggesting a more rapid repair of the tenotomy site than in SIS-treated or untreated rats. The harvested tenotomy sites in all treatment groups were characterized by marked fibroplasia and presence of macrophages. Remnants of SIS surrounded by macrophages and multi-nucleated giant cells were still present in some rats, however remnants of RCM were not observed, suggesting more rapid incorporation of RCM. The results show that RCM is equivalent to SIS as a material for repair of Achilles tendon injury and merits further study in other tendon injury models.

Endoscopic-assisted Achilles tendon repair with plantaris tendon augmentation

Six portals are made at the sides of the Achilles tendon. The plantaris tendon is harvested and retrieved to the distal-medial portal. The investing fascia of the Achilles tendon is released at the medial border of the tendon. The suture is passed through the tendon end through the medial portal and exits at the tendon surface and then the fascia and skin. The suture is retrieved at the tendon surface through the medial portal. The loops of the suture are retrieved through the proximal-medial, proximal-lateral, and lateral portals, and a loop of suture is then formed at the surface of the tendon and beyond the boundary of the tendon. The suture is passed through the tendon again in a deep-to-superficial direction within the loop and is retrieved through the proximal-medial portal. The suture is tensioned, and a locking stitch is formed. The loops of the suture are retrieved through the medial, lateral, and proximal-lateral portals. The suture is then passed through the tendon in a deep-to-superficial direction and is retrieved again through the proximal-medial portal, and the second locking stitch is formed. This is repeated 3 to 4 times over the medial side of the proximal tendon through the proximal-medial portal, and the suture is then passed to the proximal-lateral portal at the surface of the tendon. Locking stitches are then applied to the lateral side of the tendon. The same procedure is then repeated over the distal tendon with another suture. The tendon ends are approximated with the pair of sutures tied through the medial and lateral portals. The plantaris tendon is passed through the Achilles tendon with a pointed tendon passer through the proximal and distal portals. The plantaris tendon is then looped around the Achilles tendon and sutured to it.

Percutaneous and minimally invasive techniques of Achilles tendon repair

Despite the controversy regarding the best treatment for an acute Achilles tendon rupture, percutaneous and minimally invasive techniques seem to offer good results in terms of low risks of rerupture and complications with satisfactory clinical and functional outcomes. A comparison between a percutaneous surgical technique and a minimally invasive one has not been reported in the literature. We consecutively evaluated 12 patients who had a modified Ma and Griffith percutaneous Achilles tendon repair and 12 patients who had a minimally invasive technique. The same semifunctional rehabilitation protocol was used after surgery in both groups. At a minimum followup of 24 months (mean, 33 months; range, 24-42 months), we observed no reruptures or major complications in either group. Both groups had similarly high values for the American Orthopaedic Foot and Ankle Society score. The two techniques allowed equivalent time for return to work and sports. In the group of patients treated with the modified Ma and Griffith suture only, the mean loss of calf circumference in the injured leg was greater, compared with the contralateral leg. The two groups were isokinetically similar. In this study, the percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded essentially identical clinical and functional outcomes.

The Achilles tendon Total Rupture Score (ATRS): development and validation

BACKGROUND

There is a need for a patient-relevant instrument to evaluate outcome after treatment in patients with a total Achilles tendon rupture.

PURPOSE

To develop and validate a new patient-reported instrument for measuring outcome after treatment for total Achilles tendon rupture.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

Development of this instrument consisted of item generation and test construction, item reduction, validation, evaluation of structure and internal consistency, test-retest, and test for responsiveness. The final version, the Achilles tendon Total Rupture Score (ATRS), was tested for validity, structure, and internal consistency (Cronbach's alpha) on 82 patients and 52 healthy persons. A correlation analysis was performed of the ATRS with the 2 validated foot/ankle/Achilles tendon scores, the Foot and Ankle Outcome Score (FAOS) and the Swedish version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-S). Structure was evaluated with factor analysis. Test-retest reliability was evaluated on 43 patients. The ATRS responsiveness was tested on 43 patients by calculating the effect size.

RESULTS

The total score for the patients ranged from 17 to 100 with a mean (median) of 77 (85) and a standard deviation (interquartile range) of 21.4 (23). A significantly (P < .0001) higher total score was found for the healthy subjects, ranging from 94 to 100 with a mean (median) of 99.8 (100) and a standard deviation (interquartile range) of 1.1 (0). The ATRS correlated significantly (P < .01) with all subscales of the FAOS (r = 0.60-0.84) and the VISA-A-S (r = 0.78). The factor analysis gave 1 factor of importance. The internal consistency was 0.96 as measured with Cronbach's alpha. The test-retest produced an intraclass correlation coefficient of 0.98. The tests for responsiveness showed an effect size between 0.87 and 2.21.

CONCLUSION

The ATRS is a patient-reported instrument with high reliability, validity, and sensitivity for measuring outcome after treatment in patients with a total Achilles tendon rupture.

CLINICAL RELEVANCE

The ATRS is a self-administered instrument with high clinical utility, and we suggest the score for measuring the outcome, related to symptoms and physical activity, after treatment in patients with a total Achilles tendon rupture.