Free hamstrings tendon transfer and interference screw fixation for less invasive reconstruction of chronic avulsions of the Achilles tendon

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Endoscopic peroneus brevis tendon transfer for chronic ruptures of the Achilles tendon: surgical technique

Chronic Achilles tendon rupture is usually defined as a rupture diagnosed 4-6 weeks after injury. The management of chronic Achilles tendon rupture (CATR) is a topic of hot debate, and no consensus has been achieved. Surgical management of CATR is recommended. Several approaches, techniques, and grafts have been described. Open techniques carry a high risk of wound breakdown, infection, and necessitate long rehabilitation times. Surgical techniques with smaller incisions to reduce the risk of scar fibrosis, pain, and infection are becoming common. The ipsilateral tendon of the hallux flexor longus and the peroneus brevis is commonly used. Endoscopic transfer of the peroneus brevis tendon is an innovative alternative to other procedures, with comparable results of other autografts even in elite athletes. The tendon of the peroneus brevis is harvested by tendoscopy before performing a calcaneal tendon endoscopy and fixing the graft in a calcaneal tunnel using an interference screw. After surgery, an anterior splint is placed for 3 weeks with immediate forefoot weight bearing. The rehabilitation starts on the 15th postoperative day.

Surgical treatment of chronic achilles tendon rupture: An anatomical consideration of various autograft options

Background

Acute Achilles tendon rupture is a common injury and when missed leads to the development of a chronic Achilles tendon rupture. Studies suggest surgical treatment (either repair or reconstruction) for most patients with a chronic Achilles rupture due to the functional deficit caused by the lack of an intact Achilles tendon. Numerous autograft options such as the flexor hallucis longus, hamstrings, peroneal and quadriceps tendon have been used to reconstruct the Achilles tendon, either as a tendon transfer or as an interposition graft. The choice of autograft used usually depends on the size of the defect left after debridement of the Achilles tendon edges, but is often dictated by surgeon preference and tissue availability. Currently, there is no consensus as to the best autograft option.

Aims and methodology

The aim of this study was to evaluate the various autograft options used to reconstruct the Achilles tendon, and the advantages and disadvantages of using each tendon, focussing specifically on the harvesting technique, anatomical and biomechanical properties. This was done by reviewing the current published literature, supplemented by carrying out anatomical dissection in the cadaveric lab.

Results

The flexor hallucis longus is synergistically related to the Achilles tendon and biomechanically strong, however harvesting can result in weakness in big toe flexion. The peroneus brevis whilst being biomechanically strong is a much shorter tendon compared to the other autograft options. Similarly, the quadriceps tendon is also a strong tendon option, but may not be appropriate for larger chronic Achilles tendon rupture gaps. The semitendinosus tendon can be tripled/quadrupled to resemble the Achilles tendon, but is associated with higher risks of patient morbidity when harvesting the tendon.

Conclusion

Treatment of chronic Achilles tendon ruptures remains a challenge. Each autograft option has its own unique advantages and disadvantages which should be considered on a case-specific basis. Further work is required to analyse the biomechanical properties of the autograft options to determine if one option is superior.

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

PURPOSE

Achilles tendon ruptures are termed chronic after a delay in treatment for more than 4 weeks. The literature advocates surgical treatment with reconstruction to regain ankle push-off strength. The preferred technique is, however, still unknown and is often individualized. This study aims to present the technique and clinical outcome of an endoscopically assisted free semitendinosus reconstruction of chronic Achilles tendon rupture and Achilles tendon re-ruptures with delayed representation. It is hypothesized that the presented technique is a viable and safe alternative for distal Achilles tendon ruptures and ruptures with large tendon gaps.

METHOD

Twenty-two patients (13 males and 9 females) with a median (range) age of 64 (34-73) treated surgically with endoscopically assisted Achilles tendon reconstruction using a semitendinosus autograft were included. The patients were evaluated at 12 months post-operatively for Achilles tendon Total Rupture Score (ATRS), calf circumference, Achilles Tendon Resting Angle (ATRA), heel-rise height and repetitions together with tendon length determined by ultrasonography, concentric heel-rise power and heel-rise work.

RESULTS

The patients reported a median (range) ATRS of 76 (45-99) out of 100. The median (range) ATRA on the injured side was 60° (49°-75°) compared with 49.5° (40-61°), p < 0.001, on the non-injured side. Eighteen out of 22 patients were able to perform a single-leg heel-rise on the non-injured side. Sixteen patients out of those 18 (89%) were also able to perform a single heel-rise on the injured side. They did, however, perform significantly lower number of repetitions compared with the non-injured side with a median (range) heel-rise repetitions of 11 (2-22) compared with 26 (2-27), (p < 0.001), and a median (range) heel-rise height of 5.5 cm (1.0-11.0 cm) compared with 9.0 cm (5.0-11.5 cm), (p < 0.001). The median calf circumference was 1.5 cm smaller on the injured side, 37.5 cm compared with 39 cm, when medians were compared. The median (range) tendon length of the injured side was 24.8 cm (20-28.2 cm) compared with 22 cm (18.4-24.2 cm), (p < 0.001), on the non-injured side.

CONCLUSION

The study shows that endoscopically assisted reconstruction using a semitendinosus graft to treat chronic Achilles tendon ruptures and re-ruptures with delayed representation produces a satisfactory outcome. The technique can restore heel-rise height in patients with more distal ruptures or large tendon defects and is therefore a viable technique for Achilles tendon reconstruction.

LEVEL OF EVIDENCE

IV.

Achilles Tendon Lesions - Part 2: Ruptures

The increasing incidence of calcaneal tendon ruptures has substantially impacted orthopedic care and costs related to its treatment and prevention. Primarily motivated by the increasing of life expectancy, the growing use of tenotoxic drugs and erratic access to physical activity, this injury accounts for considerable morbidity regardless of its outcome. In recent years, the evolution of surgical and rehabilitation techniques gave orthopedists better conditions to decide the most appropriate conduct in acute tendon rupture. Although still frequent due to their high neglect rate, Achilles chronic ruptures currently find simpler and more biological surgical options, being supported by a new specialty-focused paradigm.

Less Invasive Fixation of Acute Avulsions of the Achilles Tendon: A Technical Note

Purpose: Nowadays, surgical treatment of acute avulsions of the Achilles tendon represents a hard challenge. There is often the possibility that the calcaneus remains completely uncovered from the tendon, making the reinsertion of its distal stub complex. At the same time, the standard open surgical technique could cause difficult wound healing because of the weak blood supply, the increasing possibility of rupture, and the bacterial contamination. To overcome these risks, less invasive procedures should be considered. Methods: We developed an innovative minimally invasive procedure for fixation of acute avulsions of the Achilles tendon employing an integration of four longitudinal stab incisions and one distal semicircular Cincinnati incision. In this way, the distal Achilles tendon stub and the calcaneal insertion are exhibited. Results: We basted the tendon through percutaneous sutures performed across the four stab incisions with a Mayo needle threaded with Ultrabraid. The procedure is repeated with another loop of Ultrabraid. After having bruised the calcaneus bone insertion of the tendon, two sites for two suture anchors were prepared using a specific hole preparation device for the anchors’ footprint. Finally, we placed two suture anchors to reinsert the tendon to the calcaneal insertion. Conclusion: Our new less invasive technique is a promising alternative optional procedure for the Achilles tendon (AT) avulsion repair allowing clear exposure of the Achilles tendon insertion, maintaining the longitudinal wholeness of the dermis, and minimizing possible associated complications.

Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears

INTRODUCTION

Very distal tears of the Achilles tendon are uncommon, and poor quality tendinous tissue of the calcaneal stump can compromise healing. Little has been published about the characteristics and surgical management of such injuries. We present a surgical technique, developed by the senior author, to restore continuity of the gastrosoleus-Achilles tendon-calcaneus complex using a free ipsilateral semitendinosus graft, and clinical outcomes of a case series of 28 consecutive patients. Our hypothesis was that this is a safe technique, and patients can return to pre-injury occupation and athletic activities.

PATIENTS AND METHODS

A total of 28 patients (mean age 46 years) underwent minimally invasive reconstruction using a free ipsilateral semitendinosus graft for acute insertional rupture of tendo Achillis. The procedure required two small incisions along the course of the Achilles tendon, and one posteromedial incision at level of the ipsilateral knee to harvest the semitendinosus tendon. Patients were assessed at minimum 2 years (range, 2-2.5 years) following the index procedure.

RESULTS

The median Achilles tendon Rupture Score (ATRS) at the latest follow-up was 88. Two patients developed a superficial wound infection. All patients returned to their preinjury occupation, whilst 22 out of 28 patients (79%), returned to their preinjury level of physical activity at a mean of 6.7 months after surgery, reporting good or excellent overall satisfaction in 88.5% of cases.

CONCLUSION

This minimally invasive technique was safe, and allowed most of patients to return to preinjury daily and sport activities within 9 months from surgery.

Optimal Outcomes for Acute Avulsion Fracture of the Achilles Tendon Treated With the Insertional Reattachment Technique: A Case Series of 31 Cases With Over 2 Years of Follow-up

BACKGROUND

Avulsion fracture of the Achilles tendon is a less common but debilitating disorder. There is a paucity of literature on this problem.

PURPOSE

To present a retrospective case series assessing the clinical outcomes of avulsion fracture of the Achilles tendon after a reattachment procedure and to identify potential factors predicting postoperative outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A consecutive case series of 35 patients with acute insertional rupture of the Achilles tendon who received a reattachment procedure between 2011 and 2017 were reviewed. All patients were measured and classified by magnetic resonance imaging (MRI) and surgical findings. Patient-reported outcomes were evaluated using the visual analog scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Foot Function Index (FFI), Tegner score, and Ankle Activity Score (AAS). The range of motion and single-legged heel raise test were also conducted for both ankles.

RESULTS

Thirty-one out of 35 (88.57%) patients were followed up for an average of 43.65 months. The VAS pain score and AOFAS Ankle-Hindfoot score improved from 4.87 ± 1.61 preoperatively to 2.07 ± 1.57 postoperatively and from 58.32 ± 18.66 preoperatively to 87.32 ± 7.53 postoperatively, respectively (both P < .001). The mean FFI, AAS, and Tegner scores after the operation were 11.84 ± 1.62, 5.71 ± 2.18, and 4.61 ± 1.31, respectively. Compared with the intact ankle, the mean deficit in dorsiflexion in the involved ankle was 9.54°± 6.25° (range, 0.59°-23.70°; P < .001) and the mean deficit in plantarflexion in the involved ankle was 6.31°± 4.02° (range, 0.24°-14.92°; P < .001). Thirty patients could perform the single-legged heel raise on the operative leg. A larger body mass index was associated with worse postoperative AOFAS and FFI outcomes. Longer follow-up predicted statistically significantly better FFI scores. Better postoperative dorsiflexion was associated with better postoperative FFI, AAS, and Tegner scores, and a statistically significant interaction was found between the VAS score and plantarflexion deficit. Age, preoperative insertional tenderness, Haglund deformity, and MRI classification showed little association with postoperative outcomes.

CONCLUSION

This study demonstrated that the reattachment procedure for acute avulsion fracture of the Achilles tendon can achieve firm fixation and promising outcomes.

Biologics in the Treatment of Achilles Tendon Pathologies

Regenerative medicine is gaining more and more space for the treatment of Achilles pathologic conditions. Biologics could play a role in the management of midportion Achilles tendinopathy as a step between conservative and surgical treatment or as an augmentation. Higher-level studies are needed before determining a level of treatment recommendation for biologic strategies for insertional Achilles tendinopathy. Combining imaging with patient's functional requests could be the way to reach a protocol for the use of biologics for the treatment of midportion Achilles tendinopathy and, for this perspective, the authors describe the Foot and Ankle Reconstruction Group algorithm of treatment.

Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears

BACKGROUND

Rupture of the Achilles tendon (AT) is frequent in young recreational athletes. Conservative management, open surgery and percutaneous/minimally invasive approaches are all advocated, and conflicting data are available. This study compared functional and anthropometric outcomes of patients who underwent open or percutaneous repair.

METHODS

A retrospective comparative study, in which 38 patients underwent open and percutaneous techniques to manage AT ruptures. For functional assessment, the calf circumference of both injured and uninjured legs was evaluated. Isokinetic testing included total plantar flexion work, peak plantar flexion torque, total dorsiflexion work peak and dorsiflexion torque. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) were evaluated at a final minimum follow-up of 12months.

RESULTS

No major complications were observed. The average time to return to sport was 9months. AOFAS and ATRS values did not differ statistically between groups. Isokinetic variables and circumference were similar in the operated and non-operated limb in both groups, and did not differ either when comparing open and percutaneous repair.

CONCLUSIONS

Open and percutaneous repair of a torn Achilles tendon produced similar functional outcomes.

Interference screw insertion angle has no effect on graft fixation strength for insertional Achilles tendon reconstruction

PURPOSE

To compare the effect of two interference screw insertion angles on the biomechanical properties of the insertional Achilles tendon (IAT) reconstruction.

METHODS

Nine matched pairs of fresh-frozen human cadaveric Achilles tendon specimens were randomized to two groups with interference screw insertion angles of 60° and 120°. The IAT reconstruction was performed by fixing the graft tendon with the interference screw. Each specimen was loaded to failure. The load at failure, stiffness, and mode of failure were documented. Differences in load at failure and stiffness were analysed.

RESULTS

There was no statistically significant difference between the 60° and 120° groups for failure load (149.137 ± 20.836 versus 155.428 ± 28.343 N, respectively, n.s.) and stiffness (14.523 ± 2.824 N/mm versus 14.727 ± 2.192 N/mm, respectively, n.s.). The most common mode of failure was the graft pulling out of the bone tunnel when the screw broke.

CONCLUSIONS

Graft fixation at two different interference screw insertion angles for IAT reconstruction exhibited equivalent biomechanical performance. When performing this procedure, surgeons may choose the interference screw insertion angle based on personal preference.

Reconstruction of chronic Achilles tendon rupture using the semitendinosus tendon: a case report

Achilles tendon rupture is a common trauma requiring surgical management. For chronic Achilles tendon rupture in particular, reconstructive surgery is desirable and several methods have been described. Here we present a case of chronic Achilles tendon rupture reconstructed using the semitendinosus tendon because of the difficulty in pulling down the proximal stump to reach the distal stump and due to an insufficient margin for hooking a suture to the distal stump. Postoperatively, the patient had a fully functional tendon and resumed his normal activities of daily living. Using this surgical technique, we expect favorable outcomes in cases of Achilles tendon rupture.

Biomechanical comparison of three methods for distal Achilles tendon reconstruction

PURPOSE

To compare the load at failure and stiffness associated with three surgical techniques for distal Achilles tendon reconstruction (AT).

METHODS

Nine matched pairs of fresh-frozen human cadaveric ATs were divided into three groups. Distal AT reconstruction was performed using suture anchors or one of two lengths of tendon overlap (10 or 5 mm). Each tendon was loaded to failure. The load at failure (N), stiffness (N/mm), and mode of failure were recorded. Differences in load at failure and stiffness were analysed.

RESULTS

Mean load at failure was significantly higher in the 10-mm group than in the 5-mm group (p < 0.05) or the suture-anchor group (p < 0.05). Load at failure did not differ significantly between the suture-anchor and 5-mm group, and stiffness did not differ significantly between any two groups. In the 10- and 5-mm groups, failure was caused by the grafts pulling out through the substance of the AT. Modes of failure varied in the suture-anchor group.

CONCLUSIONS

The load at failure was higher in the 10-mm group than in the 5-mm and suture-anchor groups. Although all three surgical techniques provide sufficient primary load-bearing ability, the 10-mm tendon-overlap technique may be more conducive to early post-operative rehabilitation.

Ipsilateral free semitendinosus tendon graft with interference screw fixation for minimally invasive reconstruction of chronic tears of the Achilles tendon

OBJECTIVE

Minimally invasive ipsilateral semitendinosus reconstruction of large chronic tears aims to be advantageous for the patient in terms of plantar flexion recovery, anthropometric measures, fast return to daily and sport activity, is safe, with low donor site co-morbidities, low risks of wound complications and neurovascular injuries.

INDICATIONS

Tendon gaps greater than 6 cm and in cases of revision surgery (rerupture).

CONTRAINDICATIONS

Diabetes, vascular diseases, previous anterior cruciate ligament (ACL) reconstruction using ipsilateral semitendinosus tendon graft.

SURGICAL TECHNIQUE

The semitendinosus tendon is harvested through an incision in the medial aspect of the popliteal fossa, and the proximal stump is exposed and mobilized through an incision performed 2 cm proximal and medial to the palpable tendon gap. We repeat the same steps distally, approaching the distal stump of the tendon through a 2.5 cm longitudinal incision made 2 cm distal and just anterior to the lateral margin of the distal stump. Through the distal incision, we expose the Kager's space and the postero-superior corner of the osteotomized calcaneum. We drill a bone tunnel into the calcaneum from dorsal to plantar using a cannulated headed reamer. The semitendinosus tendon graft is passed into the proximal stump through a medial-to-lateral small incision, its two ends are moved distally, and finally it is pulled down and shuttled through the bone tunnel. The construct is fixed to the calcaneum using an interference screw.

POSTOPERATIVE MANAGEMENT

Immobilization in a below the knee plaster cast with the foot in plantar flexion for 2 weeks, weight bearing on the metatarsal heads as tolerated, use elbow crutches, and keep the knee flexed. At 2 weeks, plaster removed, and rehabilitative exercises started, walker cast allowed.

RESULTS

Between 2008 and 2010, the procedure was performed on 28 consecutive patients (21 men and 7 women, median age 46 years). At the 2-year follow-up, average ATRS scores significantly improved (p < 0.0001) compared to average preoperative scores with good to excellent outcomes for 26 out of 28 patients (93 %); the maximum calf circumference also improved considerably whereby no clinical or functional relevance compared to the contralateral side observed. Of the 28 patients 16 (57 %) could practice sport at the same preinjury level, whereby 1 patient experienced persistent pain over the distal wound, which ameliorated after desensitization therapy.

Acute achilles tendon rupture in athletes

The incidence of AT rupture has increased in recent decades. AT ruptures frequently occur in the third or fourth decade of life in sedentary individuals who play sport occasionally. Ruptures also occur in elite athletes. Clinical examination must be followed by imaging. Conservative management and early mobilization can achieve excellent results, but the rerupture rate is not acceptable for the management of young, active, or athletic individuals. Open surgery is the most common option for AT ruptures, but there are risks of superficial skin breakdown and wound problems. These problems can be prevented with percutaneous repair.

Minimally invasive reconstruction of chronic achilles tendon ruptures using the ipsilateral free semitendinosus tendon graft and interference screw fixation

BACKGROUND

Achilles tendon ruptures represent more than 40% of all tendon ruptures requiring surgical management. About 20% of acute Achilles tendon tears are not diagnosed at the time of injury and become chronic, necessitating more complicated management than fresh injuries. Several techniques for the reconstruction of chronic tears of the Achilles tendon have been described, but the superiority of one technique over the others has not been demonstrated.

HYPOTHESIS

Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft will result in improvement of the overall function with a low rate of complications.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2010, the authors prospectively enrolled 28 consecutive patients (21 men and 7 women; median age, 46 years) with chronic closed ruptures of the Achilles tendon who had undergone reconstruction with a free semitendinosus tendon graft. They assessed the Achilles tendon Total Rupture Score (ATRS), maximum calf circumference, and isometric plantarflexion strength before surgery and at the last follow-up. Outcome of surgery and rate of complications were also recorded. The median follow-up after surgery was 31.4 months.

RESULTS

The overall result of surgery was excellent/good in 26 (93%) of 28 patients. The ATRS improved from 42 (range, 29-55) to 86 (range, 78-95) (P < .0001). In the operated leg, the maximum calf circumference and isometric plantarflexion strength were significantly improved after surgery (P < .0001); however, their values remained significantly lower than those of the opposite side (P < .0001). All patients were able to walk on tiptoes and returned to their preinjury working occupation. No infections were recorded.

CONCLUSION

Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft provides a significant improvement of symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully.

Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer

PURPOSE

The purpose of this study was to evaluate the outcomes following reconstruction of the chronic Achilles tendon ruptures with large gaps (>6 cm) using free semitendinosus tendon graft transfer.

METHODS

There were 11 consecutive patients underwent the above-mentioned surgical technique for the treatment of chronically ruptured Achilles tendon contributed in current study and were followed up prospectively for a mean of 25 ± 3 months. The intraoperative tendon defect was greater than 6 cm in all of the patients. Functional and clinical assessment was performed using The American Orthopaedic Foot and Ankle Society (AOFAS) and Achilles Tendon Rupture Score (ATRS).

RESULTS

The average AOFAS and ATRS improved significantly from 70 ± 5 and 32 ± 6 preoperatively, to 92 ± 5 and 89 ± 4 points post-operatively (P = 0.001). The range of dorsiflexion was significantly limited on the operated side (13 ± 4° vs. 17 ± 4°) (P = 0.04). All patients were able to stand on the tiptoe of injured leg, and no patient walked with a visible limp. Post-operative complications included one patient with symptomatic DVT and 2 patients with superficial infection treated nonoperatively.

CONCLUSIONS

The technique offers good clinical and functional outcomes and is safe. Reconstruction of the chronic Achilles tendon ruptures with free semitendinosus tendon graft in patients with defects greater than 6 cm is recommended.

LEVEL OF EVIDENCE

IV.

A biomechanical comparison of the primary stability of two minimally invasive techniques for repair of ruptured Achilles tendon

PURPOSE

To compare the primary stability of two minimally invasive procedures of Achilles tendon (AT) repair, namely a modified percutaneous repair of ruptured AT and the Achillon suture configuration.

METHODS

Eighteen (nine matched pairs) frozen ovine ATs were tenotomized 5 cm from the calcaneal insertion. In each pair, one tendon was randomly allocated to one of the two techniques: a modified percutaneous repair group and the Achillon device suture configuration. Specimens were tested performing an unidirectional tensile load to failure using a servo-hydraulic testing device (MTS Systems, Eden Prairie, MN, USA), controlled by an electropulse e3000 INSTRON machine (Instron Ltd, Buckinghamshire, UK). The tendons were then loaded to failure at a rate of 10 mm/s.

RESULTS

Two of the nine pairs of specimens were discarded because one specimen for each of the pair pulled out of the pneumatic clamp during mechanical testing. The remaining seven matched pairs were successfully tested. There were no differences in mean strength, mean maximum load, mean failure elongation, tension, stiffness and mode of failure between the two groups.

CONCLUSION

The Achillon-like configuration and the modified percutaneous repair of ruptured AT provided similar biomechanical performance.

Peroneus brevis tendon transfer for reconstruction of chronic tears of the Achilles tendon: a long-term follow-up study

BACKGROUND

Chronic tears of the Achilles tendon can result in substantial loss of function. Those tears with a tendon gap of up to 6.5 cm can be treated surgically with use of an autologous peroneus brevis tendon graft.

METHODS

At an average follow-up period of 15.5 years after the surgery, we examined sixteen of twenty-two patients who had undergone peroneus brevis tendon graft reconstruction for a chronic Achilles tendon tear. Clinical and functional assessment was performed.

RESULTS

All sixteen patients were able to walk on tiptoe, and no patient used a heel lift or walked with a visible limp. The maximum calf circumference of the involved limb remained significantly decreased. The involved limb was significantly less strong than the contralateral one. One patient had developed a tendinopathy of the opposite Achilles tendon, one had developed a tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon five years after the original injury.

CONCLUSIONS

The long-term results of treatment of chronic tears of the Achilles tendon by means of autologous peroneus brevis tendon grafting are encouraging. Patients retain good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.

Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon

BACKGROUND

Chronic tears of the Achilles tendon with a tendon gap exceeding 6 cm are a surgical challenge. The purpose of this study is to report the long-term results of reconstruction of such chronic Achilles tendon ruptures with use of a free autologous gracilis tendon graft.

METHODS

Twenty-one patients underwent reconstruction of a chronic rupture of the Achilles tendon. Fifteen patients were available for clinical and functional assessment on the basis of anthropometric measurements, isometric strength testing, and the Achilles Tendon Total Rupture Score after a mean duration of follow-up of 10.9 years (range, eight to twelve years).

RESULTS

All fifteen patients were able to walk on the tiptoes, and no patient used a heel lift or walked with a visible limp. At an average of 10.9 years of follow-up, the maximum calf circumference of the operatively treated leg remained substantially decreased and the operatively treated limb was significantly weaker than the contralateral, normal limb. Two patients had developed tendinopathy of the contralateral Achilles tendon, one had developed tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon eight years after the index tear.

CONCLUSIONS

The long-term results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting showed that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.

Biological strategies to enhance healing of the avascular area of the meniscus

Meniscal injuries in the vascularized peripheral part of the meniscus have a better healing potential than tears in the central avascular zone because meniscal healing principally depends on its vascular supply. Several biological strategies have been proposed to enhance healing of the avascular area of the meniscus: abrasion therapy, fibrin clot, organ culture, cell therapy, and applications of growth factors. However, data are too heterogeneous to achieve definitive conclusions on the use of these techniques for routine management of meniscal lesions. Although most preclinical and clinical studies are very promising, they are still at an experimental stage. More prospective randomised controlled trials are needed to compare the different techniques for clinical results, applicability, and cost-effectiveness.

Tissue engineered strategies for skeletal muscle injury

Skeletal muscle injuries are common in athletes, occurring with direct and indirect mechanisms and marked residual effects, such as severe long-term pain and physical disability. Current therapy consists of conservative management including RICE protocol (rest, ice, compression and elevation), nonsteroidal anti-inflammatory drugs, and intramuscular corticosteroids. However, current management of muscle injuries often does not provide optimal restoration to preinjury status. New biological therapies, such as injection of platelet-rich plasma and stem-cell-based therapy, are appealing. Although some studies support PRP application in muscle-injury management, reasons for concern persist, and further research is required for a standardized and safe use of PRP in clinical practice. The role of stem cells needs to be confirmed, as studies are still limited and inconsistent. Further research is needed to identify mechanisms involved in muscle regeneration and in survival, proliferation, and differentiation of stem cells.

Tissue engineering for rotator cuff repair: an evidence-based systematic review

The purpose of this systematic review was to address the treatment of rotator cuff tears by applying tissue engineering approaches to improve tendon healing, specifically platelet rich plasma (PRP) augmentation, stem cells, and scaffolds. Our systematic search was performed using the combination of the following terms: “rotator cuff”, “shoulder”, “PRP”, “platelet rich plasma”, “stemcells”, “scaffold”, “growth factors”, and “tissue engineering”. No level I or II studies were found on the use of scaffolds and stem cells for rotator cuff repair. Three studies compared rotator cuff repair with or without PRP augmentation. All authors performed arthroscopic rotator cuff repair with different techniques of suture anchor fixation and different PRP augmentation. The three studies found no difference in clinical rating scales and functional outcomes between PRP and control groups. Only one study showed clinical statistically significant difference between the two groups at the 3-month follow up. Any statistically significant difference in the rates of tendon rerupture between the control group and the PRP group was found using the magnetic resonance imaging. The current literature on tissue engineering application for rotator cuff repair is scanty. Comparative studies included in this review suggest that PRP augmented repair of a rotator cuff does not yield improved functional and clinical outcome compared with non-augmented repair at a medium and long-term followup.

Growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration

Intervertebral disc (IVD) degeneration is frequent, appearing from the second decade of life and progressing with age. Conservative management often fails, and patients with IVD degeneration may need surgical intervention. Several treatment strategies have been proposed, although only surgical discectomy and arthrodesis have been proved to be predictably effective. Biological strategies aim to prevent and manage IVD degeneration, improving the function and anabolic and reparative capabilities of the nucleus pulposus and annulus fibrosus cells and inhibiting matrix degradation. At present, clinical applications are still in their infancy. Further studies are required to clarify the role of growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration.

Advances in meniscal tissue engineering

Meniscal tears are the most common knee injuries and have a poor ability of healing. In the last few decades, several techniques have been increasingly used to optimize meniscal healing. Current research efforts of tissue engineering try to combine cell-based therapy, growth factors, gene therapy, and reabsorbable scaffolds to promote healing of meniscal defects. Preliminary studies did not allow to draw definitive conclusions on the use of these techniques for routine management of meniscal lesions. We performed a review of the available literature on current techniques of tissue engineering for the management of meniscal tears.

Current treatment options for tendinopathy

IMPORTANCE OF THE FIELD

Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.

AREAS COVERED IN THIS REVIEW

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy.

WHAT THE READER WILL GAIN

The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.

TAKE-HOME MESSAGE

Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.

[Surgical treatment for pain syndromes of the Achilles tendon]

Pain syndromes of the Achilles tendon (AT) include both insertional and non-insertional tendinopathy, two distinct disorders with different underlying pathophysiologies and management options, characterized by pain, impaired performance and swelling in and around the tendon. This article gives an overview of the operative treatment of pain syndromes of the Achilles tendon, including both insertional tendinopathy of the AT and tendinopathy of the main body of the AT. New minimally invasive techniques for the management of this condition, including endoscopy are also reported.

Tissue engineered biological augmentation for tendon healing: a systematic review

INTRODUCTION

Tendon injuries give rise to significant morbidity. In the last few decades, several techniques have been increasingly used to optimize tendon healing.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each scaffold and the keywords 'tendon', 'rotator cuff', 'supraspinatus tendon', 'Achilles tendon', 'growth factors', 'cytokines', 'gene therapy', 'tissue engineering', 'mesenchymal' and 'stem cells' over the years 1966-2009. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context to tissue-engineered biological augmentation for tendon healing.

AREAS OF AGREEMENT

Several new techniques are available for tissue-engineered biological augmentation for tendon healing, growth factors, gene therapy and mesenchimal stem cells.

AREAS OF CONTROVERSY

Data are lacking to allow definitive conclusions on the use of these techniques for routine management of tendon ailments.

GROWING POINTS

The emerging field of tissue engineering holds the promise to use new techniques for tendon augmentation and repair. Preliminary studies support the idea that these techniques can provide an alternative for tendon augmentation with great therapeutic potential.

AREAS TIMELY FOR DEVELOPING RESEARCH

The optimization strategies discussed in this article are currently at an early stage of development. Although these emerging technologies may develop into substantial clinical treatment options, their full impact needs to be critically evaluated in a scientific fashion.

Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review

Minimally invasive techniques for hallux valgus correction include arthroscopy, percutaneous and minimum incision surgery. In the last few decades, several techniques have been increasingly used. We performed a comprehensive search of CINAHL, Embase, Medline, HealthSTAR and the Cochrane Central Registry of Controlled Trials, from inception of the database to 4 January 2010, using various combinations of the keywords terms 'Bosch', 'PDO', 'percutaneous distal osteotomy', 'SERI', 'percutaneous', 'minimal incision', 'minimum incision', 'minimally invasive', 'less invasive', 'mini-invasive', 'hallux valgus', 'bunion', 'surgery', 'arthroscopy', 'metatarsal' 'forefoot'. Only articles published in peer reviewed journals were included in this systematic review. Several new techniques are available for minimally invasive correction of the hallux valgus. Minimally invasive correction of the hallux valgus may provide better outcome for patients who would not recover well from traditional open approaches, because of decreasing recovery and rehabilitation times, as surgical exposure and deep tissue dissection are smaller and gentler to the soft tissues. Data are lacking to allow definitive conclusions on the use of these techniques for routine management of patients with hallux valgus. Given the limitations of the current case series, especially the extensive clinical heterogeneity, it is not possible to determine clear recommendations regarding the systematic use of minimally invasive surgery for hallux valgus correction, even though preliminary results are encouraging. Studies of higher levels of evidence, concentrating on large adequately powered randomized trials, should be conducted to help answer these questions.

Achilles tendon ruptures in diabetic patients

AIM

The aim of this study is to evaluate the results of percutaneous repair of an acute AT rupture in diabetic patients.

METHOD

The study included 39 subjects who were operated at our institution. We performed pre-operative evaluations the day of surgery, and report the results of post-operative evaluation at the final follow-up.

RESULTS

The Achilles tendon total rupture score had a post-operative average rating of 70.4 ± 13 (range 55-92). All patients were able to fully weight bear on the operated limb by the end of the eighth post-operative week. Eight patients suffered from a superficial infection of the surgical wound.

CONCLUSION

In conclusion, percutaneous repair of the AT is a viable option for diabetic patients.

Achilles tendon ruptures in elite athletes

BACKGROUND

The management of Achilles tendon (AT) ruptures in elite athletes can be challenging. We performed a retrospective review of prospectively collected data study to evaluate the results of percutaneous repair of an acute AT rupture in elite athletes.

MATERIALS AND METHODS

Seventeen elite athletes with prodromal tendinous problems sustained an acute tear of the AT and underwent percutaneous surgical repair. We performed preoperative evaluations the day of surgery, and report the results of postoperative evaluation at a final followup at an average of 72 months from the procedure. Each patient was evaluated for limb dominance, trauma history, duration and type of preoperative symptoms, and postoperative AT Total Rupture Score (ATRS).

RESULTS

All patients were able to fully weightbear on the operated limb by the end of the 8th postoperative week. The average time to return to full sport participation was 4.8±0.9 months. Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound.

CONCLUSION

Our study suggests that percutaneous repair of the AT is a good option for elite athletes, allowing a safe and prompt return to sport activities.

Less-invasive reconstruction of chronic achilles tendon ruptures using a peroneus brevis tendon transfer

BACKGROUND

A less-invasive technique to reconstruct chronic Achilles tendon rupture with transfer of the tendon of peroneus brevis is suitable in patients with a tendon gap less than 6 cm.

PURPOSE

To report the results of a longitudinal study on reconstruction of chronic Achilles tendon rupture using a less-invasive peroneus brevis repair through 2 paramidline incisions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-two patients underwent surgery for chronic Achilles tendon rupture with a tendon gap during surgery less than 6 cm, occurring between 60 days and 9 months preoperatively. All participants were prospectively followed for 5 to 8 years; final review was performed at 48.4 ± 13.5 months from the operation. Clinical and functional assessment (anthropometric measurements, isometric strength, postoperative Achilles tendon total rupture score) was performed.

RESULTS

All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. No patient developed a clinically evident deep vein thrombosis or sustained a rerupture. Five patients were managed nonoperatively after a superficial infection of one of the surgical wounds. At final review, the maximum calf circumference remained significantly decreased in the operated leg (39.2 ± 6.2 cm [side with rupture] vs 40.9 ± 7.0 cm [uninjured side]; P = .04). The operated limb was significantly less strong than the nonoperated one (231.2 ± 132.4 N vs 275.3 ± 150.2 N; P = .033). The Achilles tendon total rupture score at final follow-up was 92.5 ± 14.2.

CONCLUSION

The management of chronic Achilles tendon tears by a less-invasive peroneus brevis repair is technically demanding but safe. It allows good recovery, even in patients with a chronic rupture of 9 months' duration. These patients should be warned that they are at risk for postoperative complications and that their ankle plantar flexion strength is likely to be reduced.

Minimally invasive surgery for Achilles tendon pathologies

Minimally invasive trauma and orthopedic surgery is increasingly common, though technically demanding. Its use for pathologies of the Achilles tendon (AT) hold the promise to allow faster recovery times, shorter hospital stays, and improved functional outcomes when compared to traditional open procedures, which can lead to difficulty with wound healing because of the tenuous blood supply and increased chance of wound breakdown and infection. We present the recent advances in the field of minimally invasive AT surgery for tendinopathy, acute ruptures, chronic tears, and chronic avulsions of the AT. In our hands, minimally invasive surgery has provided similar results to those obtained with open surgery, with decreased perioperative morbidity, decreased duration of hospital stay, and reduced costs. So far, the studies on minimally invasive orthopedic techniques are of moderate scientific quality with short follow-up periods. Multicenter studies with longer follow-up are needed to justify the long-term advantages of these techniques over traditional ones.