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Maffulli N, Spiezia F. In response of "Zeybek H, Cici H, Çıklaçandır S. A comparative biomechanical study of the krackow suture technique with three common percutaneous suture techniques in the treatment of Achilles tendon ruptures" [Foot Ankle Surg. 30 (2024) 366-370]. Foot Ankle Surg 2024:S1268-7731(24)00184-X. [PMID: 39181831 DOI: 10.1016/j.fas.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Accepted: 08/05/2024] [Indexed: 08/27/2024]
Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary University of London, London, England, UK.
| | - Filippo Spiezia
- Dipartimento di Scienze, Facoltà di Medicina e Chirurgia, Università della Basilicata, Italy; Department of Orthopaedic and Trauma Surgery, Ospedale San Carlo, Via Potito Petrone, 85100 Potenza, Italy
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Carmont MR, Nilsson-Helander K, Carling M. 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. BMC Musculoskelet Disord 2024; 25:610. [PMID: 39085820 PMCID: PMC11292938 DOI: 10.1186/s12891-024-07630-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 06/25/2024] [Indexed: 08/02/2024] Open
Abstract
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.
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Affiliation(s)
- Michael R Carmont
- Department of Trauma & Orthopaedic Surgery, Shrewsbury & Telford Hospital NHS Trust, Shropshire, UK.
- University of Keele, Staffordshire, UK.
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Mölndal Hospital University of Gothenburg, Gothenburg, Sweden
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Malin Carling
- Department of Orthopaedic Surgery, Mölndal Hospital University of Gothenburg, Gothenburg, Sweden
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Saxena A, Maffulli N, Jin A, Isa E, Arthur WP, Asthana S. Acute Achilles Tendon Rupture Repair in Athletically Active Patients: Results on 188 Tendons. J Foot Ankle Surg 2021; 60:935-940. [PMID: 33947591 DOI: 10.1053/j.jfas.2021.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 02/03/2023]
Abstract
We report on the outcome of acute Achilles tendon ruptures by a single surgeon using open and percutaneous techniques was performed. This prospective study included 186 patients with 188 ruptured Achilles tendons. A traditional open technique was primarily performed on patients from January 2001 to December 2011. From January 2012 to January 2018, a percutaneous repair was primarily performed. Outcome measures included the Roles and Maudsley (RM) score, ability to perform a single leg heel raise, calf atrophy and return to activity. There were 149 males (average age 42.5 ± 12.7 years) and 39 females (average age 41.7 ± 11.4 years). Of the 188 ruptured tendons (92 repairs on the right Achilles and 96 on the left), 103 were repaired percutaneously and 85 had open repairs. There were 18 (9.6%) complications. Three re-ruptures occurred, one following open and two following percutaneous repairs, all within 12 weeks of the original repair. Two patients developed a Venousthromboembolism (1.0%). Thirteen patients had suture reactions; three infections (1.6%), 11 wound complications (5.8%), and 3 required surgical excision of the suture material (1.6%). Non-absorbable sutures were associated with more wound complications and were more frequently used in open repairs (p = .003). Patients who underwent open repair experienced more wound complications (p = .0001). Patients who underwent percutaneous repair using absorbable suture experienced a lower rate of overall complications (p = .0007). Basketball (n = 29) was the most common sport during which ruptures occurred. Return to activity (RTA) was 8.2 ± 2.9 months. There was no difference for RTA between males and females (p = .54) and RM scores (p= .69), nor surgical technique, and no difference for RTA based on the desired activity (p = .47). 123 of the 188 patients returned to their desired activity (65.5%). There was a statistically significant evidence of a positive association between inability to perform heel-raises and decreased activity (p = .01).
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Affiliation(s)
- Amol Saxena
- Department of Sports Medicine, Sutter-PAMF, Palo Alto, CA.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine, Surgery and Dentistry, Salerno, Italy; Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK; School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, UK
| | - Anqi Jin
- PAMF Research Institute, Researcher, Palo Alto, CA
| | | | | | - Saumya Asthana
- Rosalind Franklin University, Scholl College, Chicago IL
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Batista JP, Abdelatif NMN, Del Vecchio JJ, Diniz P, Pereira H. Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures: A Prospective Case Series Report With a Minimum of 18 Months' Follow-Up. J Foot Ankle Surg 2021; 59:927-937. [PMID: 32527698 DOI: 10.1053/j.jfas.2019.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/18/2019] [Accepted: 12/22/2019] [Indexed: 02/03/2023]
Abstract
Acute Achilles tendon rupture can be treated either surgically or nonsurgically. The flexor hallucis longus (FHL) has been used successfully in patients with large chronic Achilles tendon defects. The aim of this study was to describe the clinical outcomes of isolated endoscopic FHL transfer in patients with acute Achilles tendon ruptures at a minimum follow-up of 18 months. Fifty-six male patients with an average age of 36.3 years who underwent endoscopic FHL transfer as a treatment for acute Achilles tendon ruptures were included. Follow-up was for a mean (± standard deviation) of 27.5 ± 7.29 months. At 18 months postoperatively, the Achilles tendon total rupture score mean was 95 ± 4.26, and the American Orthopaedic Foot and Ankle Society score was a mean of 96.4 ± 4.31. The median value for FHL tendon dynamometry on the surgical side was 95.72 (range 70.1 to 142), and 100.7 (range 68 to 161) for the nonoperated side. Mean ankle plantarflexion strength at 18 months was 19.19 ± 2.55 kg • m compared with the uninjured side of 19.27 ± 2.16 kg • m. Relative Achilles tendon resting angle showed a mean of -0.25° ± 2.43°. Magnetic resonance imaging performed at a minimum of 18 months postoperatively showed a homogeneous continuous Achilles tendon signal for 43 patients and heterogeneous signal intensity in 13 patients (23.21%). No patients reported any great toe complaints or symptomatic deficits of flexion strength. No neurovascular or skin complications were encountered. The current study demonstrated satisfactory and comparable results with minimal complications when using the endoscopic FHL tendon transfer in surgical management of acute Achilles tendon ruptures, compared with the currently used methods.
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Affiliation(s)
- Jorge Pablo Batista
- Head, Ankle and Knee Section, Orthopaedics Department, Centro Artroscópico Jorge Batista SA, Buenos Aires, Argentina; Head, Soccer Medical Department, Department of Sport Medicine, Club Atlético Boca Juniors, Buenos Aires, Argentina
| | | | - Jorge Javier Del Vecchio
- Head, Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro. Hospital Universitario, Buenos Aires, Argentina; Professor, Department of Kinesiology and Physiatry, Universidad Favaloro, Buenos Aires, Argentina
| | - Pedro Diniz
- Orthopaedic Surgeon, Hospital de Sant'Ana, Parede, Portugal; PhD Student, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Portugal
| | - Helder Pereira
- Orthopedic Surgeon, Orthopedic Department of Póvoa de Varzim, Ripoll y De Prado Sports Clinic, Murcia-Madrid, Spain; Orthopedic Surgeon, FIFA Medical Centre of Excellence; ICVS/3B's, PT Government Associate Laboratory, Porto, Portugal; Orthopedic Surgeon, ICVS/3B's, PT Government Associate Laboratory - Minho University, Braga, Portugal
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Less Invasive Fixation of Acute Avulsions of the Achilles Tendon: A Technical Note. ACTA ACUST UNITED AC 2020; 56:medicina56120715. [PMID: 33352626 PMCID: PMC7766519 DOI: 10.3390/medicina56120715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 11/23/2022]
Abstract
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.
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Maffulli N, D'Addona A, Maffulli GD, Gougoulias N, Oliva F. Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results As Compared With Acute Repair. Am J Sports Med 2020; 48:1181-1188. [PMID: 32176527 DOI: 10.1177/0363546520908592] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Minimally invasive repair of acute Achilles tendon ruptures has been performed for several years, resulting in reduced morbidity as compared with open repair. HYPOTHESIS A minimally invasive technique can be used to manage Achilles tendon ruptures in patients presenting between 14 and 30 days from injury. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS We prospectively recruited 21 consecutive patients who presented between 14 and 30 days after the index injury, and we compared them with 21 patients who were matched according to sex, age (±2 years), and level of activity, who presented within 14 days of the index injury. All patients underwent the same minimally invasive procedure under local anesthesia: a core suture repair consisting of a modified Bunnell suture in the proximal stump and a modified Kessler suture in the distal stump. RESULTS At 12 months after minimally invasive repair, patients with delayed treatment had a median Achilles tendon rupture score of 91 (SD, 2.4; range, 87-96) as compared with 91 (SD, 2.2; range, 86-96) in patients treated acutely, who presented at a median 2.4 days (range 1-6 days) from the injury. There were no significant differences between groups in terms of mean (SD) Achilles tendon resting angle: delayed repair group, -3.9° (2.0); acute repair group, -3.7° (1.9) (P = .69). No patient in either group developed a wound infection. One patient in the acute group experienced an iatrogenic sural nerve injury. CONCLUSION Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patient treated <14 after injury.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, UK.,School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Alessio D'Addona
- Department of Public Health, Section of Orthopaedics and Trauma Surgery, School of Medicine and Surgery "Federico II," Naples, Italy
| | | | - Nikolaos Gougoulias
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Frimley, UK.,Foot Surgery Private Practice, Thessaloniki and Athens, Greece
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Italy
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Biomechanical properties of different techniques used in vitro for suturing mid-substance Achilles tendon ruptures. Clin Biomech (Bristol, Avon) 2017; 50:78-83. [PMID: 29032307 DOI: 10.1016/j.clinbiomech.2017.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 08/18/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Dresden technique preserves the paratenon during Achilles tendon repair and may improve the plantarflexor mechanism when combined with mobilization during early rehabilitation. However, the surgical repair design for Achilles tendon ruptures can affect rates of re-rupture or lengthening. Therefore, the aim of this study was to determine the biomechanical properties of the Krackow, Double-Kessler, Double-Dresden, and Triple-Dresden techniques used for repairing mid-substance Achilles tendon ruptures during cyclical and maximum traction. METHODS Sixty mid-substance bovine tendons repaired after transverse rupturing were divided randomly into four groups by repair technique: Krackow, Double-Kessler, Double-Dresden, and Triple-Dresden. Cyclical tractions of 4.7, 5.8, 7.9, and 11.7mm (equivalent to 5°, 8°, 10°, and 15° of dorsal flexion, respectively) were applied to determine gapping, tensile strength, nominal suture stress, repair deformation, and specimens with clinical failure (gap>5mm). Maximal traction was applied to measure maximum strength and failure type (i.e. suture, knot, or tendon). FINDINGS The Triple-Dresden technique resulted in decreased gapping, nominal suture stress, repair deformation, and quantity of specimens with clinical failure as compared to the other techniques. Furthermore, Triple-Dresden tendons showed greater comparative tensile and maximum strength. During maximal traction testing, this technique presented tendon failure, whereas the Krackow, Double-Kessler, and Double-Dresden techniques had suture failures. INTERPRETATION Triple-Dresden repair results in better cyclical and maximum traction strengths, suggesting that this technique might be more appropriate when performing early mobilization after mid-substance Achilles tendon rupture repair.
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Carmont MR, Zellers JA, Brorsson A, Olsson N, Nilsson-Helander K, Karlsson J, Silbernagel KG. Functional Outcomes of Achilles Tendon Minimally Invasive Repair Using 4- and 6-Strand Nonabsorbable Suture: A Cohort Comparison Study. Orthop J Sports Med 2017; 5:2325967117723347. [PMID: 28856168 PMCID: PMC5571770 DOI: 10.1177/2325967117723347] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of management of Achilles tendon rupture is to reduce tendon lengthening and maximize function while reducing the rerupture rate and minimizing other complications. Purpose: To determine changes in Achilles tendon resting angle (ATRA), heel-rise height, patient-reported outcomes, return to play, and occurrence of complications after minimally invasive repair of Achilles tendon ruptures using nonabsorbable sutures. Study Design: Cohort study; Level of evidence, 3. Methods: Between March 2013 and August 2015, a total of 70 patients (58 males, 12 females) with a mean age of 42 ± 8 years were included and evaluated at 6 weeks and 3, 6, 9, and 12 months after repair of an Achilles tendon rupture. Surgical repair was performed using either 4-strand or 6-strand nonabsorbable sutures. After surgery, patients were mobilized, fully weightbearing using a functional brace. Early active movement was permitted starting at 2 weeks. Results: There were no significant differences in the ATRA, Achilles Tendon Total Rupture Score (ATRS), and Heel-Rise Height Index (HRHI) between the 4- and 6-strand repairs. The mean (SD) relative ATRA was –13.1° (6.6°) (dorsiflexion) following injury; this was reduced to 7.6° (4.8°) (plantar flexion) directly after surgery. During initial rehabilitation at 6 weeks, the relative ATRA was 0.6° (7.4°) (neutral) and –7.0° (5.3°) (dorsiflexion) at 3 months, after which ATRA improved significantly with time to 12 months (P = .005). At 12 months, the median ATRS was 93 (range, 35-100), and the mean (SD) HRHI and Heel-Rise Repetition Index were 81% (0.22%) and 82.9% (0.17%), respectively. The relative ATRA at 3 and 12 months correlated with HRHI (r = 0.617, P < .001 and r = 0.535, P < .001, respectively). Conclusion: Increasing the number of suture strands from 4 to 6 does not alter the ATRA or HRHI after minimally invasive Achilles tendon repair. The use of a nonabsorbable suture during minimally invasive repair when used together with accelerated rehabilitation did not prevent the development of an increased relative ATRA. The ATRA at 3 months after surgery correlated with heel-rise height at 12 months.
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Affiliation(s)
- Michael R Carmont
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom.,Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jennifer A Zellers
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicklas Olsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Kungsbacka Hospital, Kungsbacka, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Carmont MR, Kuiper JH, Grävare Silbernagel K, Karlsson J, Nilsson-Helander K. Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures. J Exp Orthop 2017; 4:26. [PMID: 28733950 PMCID: PMC5520830 DOI: 10.1186/s40634-017-0101-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/14/2017] [Indexed: 12/28/2022] Open
Abstract
Background Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. Methods Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure. Results Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. Conclusion The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.
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Affiliation(s)
- Michael R Carmont
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital, Telford, UK. .,Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Jan Herman Kuiper
- Department of Biomechanical Engineering, The Robert Jones & Agnes Hunt District General Hospital, University of Keele, Keele, UK
| | | | - Jón Karlsson
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedic Surgery, Kungsbacka Hospital, Kungsbacka, Sweden
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Alviti F, Gurzì M, Santilli V, Paoloni M, Padua R, Bernetti A, Bernardi M, Mangone M. Achilles Tendon Open Surgical Treatment With Platelet-Rich Fibrin Matrix Augmentation: Biomechanical Evaluation. J Foot Ankle Surg 2017; 56:581-585. [PMID: 28476390 DOI: 10.1053/j.jfas.2017.01.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Indexed: 02/03/2023]
Abstract
The relationship between surgical technique and ankle biomechanical properties after surgery for acute rupture of the Achilles tendon (ATR) has not yet been fully investigated. Platelet-rich fibrin (PRF) matrices seem to play a central role in the complex processes of tendon healing. Our aim was to analyze the biomechanical characteristics, stiffness, and mechanical work of the ankle during walking in patients who had undergone surgery after ATR with and without PRF augmentation. We performed a retrospective review of all consecutive patients who had been treated with surgical repair after ATR. Of the 20 male subjects enrolled, 9 (45%) had undergone conventional open repair of the Achilles tendon using the Krackow technique (no-PRF) and 11 (55%) had undergone surgery with PRF augmentation. An additional 8 healthy subjects were included as a control group. A gait analysis evaluation was performed at 6 months after surgery. The percentage of the stance time of the operated leg, double-support time of the healthy leg, and net work of the ankle during the gait cycle showed statistically significant differences between the no-PRF and the healthy group (p < .005). No differences were found between the PRF and healthy groups. Treatment with suture and PRF augmentation could result in significant functional improvements in term of efficiency of motion.
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Affiliation(s)
- Federica Alviti
- Research Fellow, Department of Physical Medicine and Rehabilitation, Sapienza University of Rome, Rome, Italy.
| | - Michele Gurzì
- Surgeon, Department Orthopaedics and Traumatology, Sapienza University of Rome, Rome, Italy
| | - Valter Santilli
- Professor, Department of Physical Medicine and Rehabilitation, Sapienza University of Rome, Rome, Italy
| | - Marco Paoloni
- Assistant Professor, Department of Physical Medicine and Rehabilitation, Sapienza University of Rome, Rome, Italy
| | - Roberto Padua
- GLOBE, Evidence-Based Orthopedics Working Group of Italian Society of Orthopedics and Traumatology, Rome, Italy
| | - Andrea Bernetti
- Research Fellow, Department of Physical Medicine and Rehabilitation, Sapienza University of Rome, Rome, Italy
| | - Marco Bernardi
- Professor, Department of Physiology and Pharmacology, Vittorio Erspamer School of Specialty and Sports Medicine, Sapienza University of Rome, Rome, Italy
| | - Massimiliano Mangone
- Assistant Professor, Department of Physical Medicine and Rehabilitation, Sapienza University of Rome, Rome, Italy
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De la Fuente C, Peña y Lillo R, Carreño G, Marambio H. Prospective randomized clinical trial of aggressive rehabilitation after acute Achilles tendon ruptures repaired with Dresden technique. Foot (Edinb) 2016; 26:15-22. [PMID: 26802945 DOI: 10.1016/j.foot.2015.10.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/04/2015] [Accepted: 10/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rupture of the Achilles tendon is a common injury during working years. Aggressive rehabilitation may provide better outcomes, but also a greater chance of re-rupture. OBJECTIVE To determine if aggressive rehabilitation has better clinical outcomes for Achilles tendon function, Triceps surae function, one-leg heel rise capacity and lower complication rate during twelve weeks after percutaneous Achilles tendon repair compared to conventional rehabilitation. DESIGN Randomized controlled trial. METHOD Thirty-nine patients were prospectively randomized. The aggressive group (n=20, 41.4 ± 8.3 years) received rehabilitation from the first day after surgery. The conventional group (n=19, 41.7 ± 10.7 years) rested for 28 days, before rehabilitation started. The statistical parameters were the Achilles tendon rupture score (ATRS), verbal pain scale, time to return to work, pain medication consumption, Achilles tendon strength, dorsiflexion range of motion (RoM), injured-leg calf circumference, calf circumference difference, one-leg heel rise repetition and difference, re-rupture rate, strength deficit rate, and other complication rates. Mixed-ANOVA and Bonferroni's post hoc test were performed for multiple comparisons. Student's t-test was performed for parameters measured on the 12th week. RESULTS The aggressive group with respect to the conventional group had a higher ATRS; lower verbal pain score; lower pain medication consumption; early return to work; higher Achilles tendon strength; higher one-leg heel rise repetitions; and lower one-leg heel rise difference. The re-rupture rate was 5% and 5%, the strength deficit rate was 42% and 5%, and other complications rate was 11% and 15% in the conventional and aggressive group, respectively. CONCLUSION Patients with Dresden repair and aggressive rehabilitation have better clinical outcomes, Achilles tendon function and one-leg heel rise capacity without increasing the postoperative complications rate after 12 weeks compared to rehabilitation with immobilization and non-weight-bearing during the first 28 days after surgery.
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Affiliation(s)
- Carlos De la Fuente
- Biomechanics Unit, Centro de Investigaciones Médicas del Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile; Carrera de Kinesiología, UDA Cs Salud, Facultad Medicina, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile; Mechanics Department, Engineer Faculty, USACH, Santiago 717835, Chile; Kinesiology and Clinical Biomechanics Program, UMCE, Santiago 7780450, Chile.
| | - Roberto Peña y Lillo
- Foot and Ankle Unit, Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile; Servicio de Kinesiterapia y Terapia Ocupacional, Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile.
| | - Gabriel Carreño
- Laboratorio de Movimiento Humano, Escuela de Kinesiología, Facultad de Salud y Odontología, Universidad Diego Portales, Santiago 8370109, Chile; Facultad de Ciencias de la Salud, Universidad Iberoamericana de Ciencias y Tecnología, Santiago 8330440, Chile.
| | - Hugo Marambio
- Trauma Service, Clínica Santa María, Santiago 7520378, Chile; Exercise Science Laboratory, School of Kinesiology, Faculty of Medicine, Universidad Finis Terrae, Santiago 7501015, Chile.
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Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture - Development of an evidence-based treatment protocol. Injury 2014; 45:1782-90. [PMID: 25059505 DOI: 10.1016/j.injury.2014.06.022] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/29/2014] [Indexed: 02/02/2023]
Abstract
The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period. Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently, the aim of our study was to systematically search the evidence available and define a precise rehabilitation programme after operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence. We performed a systematic literature search in Medline, Embase and Cochrane library. We identified twelve randomized controlled trials comparing different treatment regimes after operative repair of the Achilles tendon. Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity. Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens time to return to work and sports significantly. Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation. No study found an increased rerupture rate for the more progressive treatment. In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied.
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Affiliation(s)
- Mareen Brumann
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich
| | - Sebastian F Baumbach
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich
| | - Wolf Mutschler
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich
| | - Hans Polzer
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich.
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Ozsoy MH, Cengiz B, Ozsoy A, Aksekili MAE, Yucel M, Fakioglu O, Dincel VE, Aydogan NH. Minimally invasive Achilles tendon repair: a modification of the Achillon technique. Foot Ankle Int 2013; 34:1683-8. [PMID: 24045854 DOI: 10.1177/1071100713505754] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of the study was to present the results of a new minimally invasive operative method for Achilles tendon (AT) ruptures that could reduce nerve injuries and add no extra cost. METHODS Thirteen patients with acute AT ruptures who were treated with minimally invasive surgery and followed for a minimum of 12 months were included. At the latest follow-up, American Orthopaedic Foot & Ankle Society (AOFAS) score, calf diameters, ability to walk on tiptoe, and ultrasound examination were evaluated. The average age was 42.8 years (range, 31-62 years). Average follow up was 24.5 months (range, 12-34 months). RESULTS AOFAS score was 92.5 (range, 85-100). Average calf diameters on the operated and nonoperated extremities were 38.9 cm (range, 36-44 cm) and 38.9 cm (range, 36-41 cm), respectively. On ultrasound examination, the site of the rupture was found to be 46.2 mm proximal from the calcaneal insertion, and the operated side was found to be significantly thicker than the nonoperated side (P = .008). There was 1 deep vein thrombosis, which recovered without sequelae. There were no wound problems, reruptures, or nerve injuries. CONCLUSIONS This new minimally invasive operative method was successful, showing good functional results and low complication rates. In our experience, the use of 3 continuous polyester sutures was less irritable with 3 knots. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Mehmet Hakan Ozsoy
- Ankara Training and Research Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey
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Abstract
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.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, Trigoria, Rome 00128, Italy.
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Kołodziej L, Bohatyrewicz A, Kromuszczyńska J, Jezierski J, Biedroń M. Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study--preliminary report. INTERNATIONAL ORTHOPAEDICS 2012; 37:625-9. [PMID: 23250350 PMCID: PMC3609980 DOI: 10.1007/s00264-012-1737-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 11/20/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results. METHOD We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon(®) device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months. RESULTS No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports. CONCLUSION After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.
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Affiliation(s)
- Lukas Kołodziej
- Department of Orthopaedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland.
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