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Wagers K, Ofori-Atta BS, Tucker W, Presson AP, Nixon D. Evaluation of Costs Associated With Acute Achilles Tendon Repair. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241238215. [PMID: 38510514 PMCID: PMC10953012 DOI: 10.1177/24730114241238215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Background Increasing attention is being paid to the costs associated with various orthopaedic surgeries. Here, we studied the factors that influence costs associated with surgically treated acute Achilles tendon tears. Methods We retrospectively identified patients with surgically repaired acute Achilles tendon tears, excluding insertional ruptures or chronic tendon issues. Using the Value Driven Outcome (VDO) tool from our institution, we assessed total direct costs as well as facility costs. Briefly, the VDO tool includes an item-level database that can capture detailed cost data-costs are then reported as relative mean data. Cost variables were adjusted to 2022 US dollars, and total direct cost was compared with patient characteristics using gamma regressions to report cost ratios with 95% CIs. Results Our cohort consisted of 224 patients with Achilles tendon tears surgically repaired by one of 4 fellowship-trained orthopaedic foot and ankle surgeons. There were no differences in demographics, total direct costs, or facility costs based on surgical positioning (prone n = 156, supine n = 68). Open repairs (n = 215), compared with percutaneous techniques (n = 9) that used commercially available instrumentation, had 37% less total direct costs (P < .001, 95% CI 0.55-0.72). Compared with surgery at a main academic hospital (n = 15), procedures at an ambulatory care center (n = 207) had 19% lower total direct costs (P = .040, 95% CI 0.66-0.99) and 41% lower facility costs (P < .001, 95% CI 0.5-0.7). Conclusion Improving cost-effective orthopaedic care remains an increasingly important goal. Patient positioning for Achilles tendon repair does not appear to have meaningful impacts on cost. When clinically appropriate, considering surgery location at an ambulatory center appears to reduce surgical costs. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Kade Wagers
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Blessing S. Ofori-Atta
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - William Tucker
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Angela P. Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Devon Nixon
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT, USA
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Bronheim RS, Shu HT, Jami M, Hsu NN, Aiyer AA. Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications? FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231205306. [PMID: 37886622 PMCID: PMC10599117 DOI: 10.1177/24730114231205306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Background Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. Methods We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Results Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94). Conclusion The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Rachel S. Bronheim
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Henry T. Shu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Meghana Jami
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Nigel N. Hsu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Amiethab A. Aiyer
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Hoskins T, Patel J, Choi JH, Fitzpatrick B, Begley B, Mazzei CJ, Harrington CJ, Miller JM, Wittig JC, Epstein D. Mini-Open Achilles Tendon Repair: Improving Outcomes While Decreasing Complications. Foot Ankle Spec 2023; 16:363-369. [PMID: 35249403 DOI: 10.1177/19386400221078671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An acute rupture of the Achilles tendon is a traumatic injury that can cause considerable morbidity and reduced function. Nonoperative intervention may put patients at higher risk of rerupture, whereas surgical intervention carries risk of infection, wound complications, and iatrogenic nerve injury. The mini-open Achilles tendon repair technique has been popularized in helping decrease complications. The goal of this study was to examine and compare the functional outcomes and rate of complications in patients treated with a mini-open repair technique versus a traditional open repair for acute Achilles tendon ruptures. A retrospective review was performed of all patients with a complete Achilles tendon rupture that were treated by a single foot and ankle fellowship-trained surgeon. Functional outcome scores were assessed using the American Orthopaedic Foot and Ankle scoring system (AOFAS) and the Achilles Tendon Rupture Score (ATRS). Eighty-one patients with a complete Achilles tendon rupture underwent mini-open repair and 22 patients underwent traditional open repair surgery between 2013 and 2020. The mean follow-up was 38.40 months (range, 12-71). Mean preoperative AOFAS and ATRS improved in the mini-open group from 45.60 and 47.18 respectively, to 90.29 and 87.97 after surgery (p < .05). Mean preoperative AOFAS and ATRS scores for the traditional open repair (n = 22) cohort were 44.02 and 42.27, respectively. Postoperatively, the AOFAS and ATRS scores improved to 85.27 and 86.64 (P value < .05), respectively. There was no statistically significant difference in postoperative ATRS scores. However, the mini-open repair group showed a statistically higher postoperative AOFAS score (90.30) than the traditional open-repair group (85.27) (P value < .05). The overall complication rate for our study was 2.9% (2 mini-open repair and 1 traditional open repair). The complication rate in the mini-open repair group and traditional open repair cohort were 2.4% and 4.5%, respectively (P value > .05). One patient in the mini-open repair cohort (1.2%) reruptured his Achilles tendon 4 months postoperatively. A second patient in the mini-open repair group (1.2%) developed a superficial skin infection and suture irritation. One patient (4.5%) in the traditional open repair group developed a superficial skin infection. There were no sural nerve injuries in our series. The mini-open approach to repair a ruptured Achilles tendon is a viable treatment option to decrease the incidence rate of postoperative complications and rerupture rates while also producing a superior cosmetic result.Level of Evidence: 3 (retrospective cohort study N ≥ 30).
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Affiliation(s)
- Tyler Hoskins
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Jay Patel
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Joseph H Choi
- Department of Orthopaedic Surgery, St. Joseph's Medical Center, Paterson, New Jersey
| | - Brendan Fitzpatrick
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Brian Begley
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Chris J Mazzei
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Colin J Harrington
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - Justin M Miller
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - James C Wittig
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
| | - David Epstein
- Department of Orthopaedic Surgery, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey
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Shoap S, Backer HC, Freibott CE, Ferrer XE, Polzer H, Turner Vosseller J. Rerupture and wound complications following Achilles tendon repair: A systematic review. J Orthop Res 2023; 41:845-851. [PMID: 35864743 DOI: 10.1002/jor.25419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/06/2022] [Accepted: 07/16/2022] [Indexed: 02/04/2023]
Abstract
Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.
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Affiliation(s)
- Seth Shoap
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida, USA
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Henrik C Backer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Christina E Freibott
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Xavier E Ferrer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Hans Polzer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - James Turner Vosseller
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- Jacksonville Orthopaedic Institute, Jacksonville, Florida, USA
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Attia AK, Mahmoud K, d'Hooghe P, Bariteau J, Labib SA, Myerson MS. Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2023; 51:825-836. [PMID: 34908499 DOI: 10.1177/03635465211053619] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair. PURPOSE The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials. STUDY DESIGN Meta-analysis; Level of evidence, 1. METHODS Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time. RESULTS There were 10 RCTs that qualified for the meta-analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], -0.73 [95% CI, -1.70 to 0.25]; P = .14; I2 = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I2 = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I2 = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I2 = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I2 = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I2 = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I2 = 15%). CONCLUSION Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.
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Affiliation(s)
- Ahmed Khalil Attia
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Pieter d'Hooghe
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Jason Bariteau
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sameh A Labib
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mark S Myerson
- University of Colorado School of Medicine, Aurora, Colorado, USA
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Murdock CJ, Ochuba AJ, Xu AL, Snow M, Bronheim R, Vulcano E, Aiyer AA. Operative vs Nonoperative Management of Achilles Tendon Rupture: A Cost Analysis. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231156410. [PMID: 36911422 PMCID: PMC9998413 DOI: 10.1177/24730114231156410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Background Achilles tendon rupture (ATR) is a common injury with a growing incidence rate. Treatment is either operative or nonoperative. However, evidence is lacking on the cost comparison between these modalities. The objective of this study is to investigate the cost differences between operative and nonoperative treatment of ATR using a large national database. Methods Patients who received treatment for an ATR were abstracted from the large national commercial insurance claims database, Marketscan Commercial Claims and Encounters Database (n = 100 825) and divided into nonoperative (n = 75 731) and operative (n = 25 094) cohorts. Demographics, location, and health care charges were compared using multivariable regression analysis. Subanalysis of costs for medical services including clinic visits, imaging studies, opioid usage, and physical therapy were conducted. Patients who underwent secondary repair were excluded. Results Operative treatment was associated with increased net and total payments, coinsurance, copayment, deductible, coordination of benefits (COB) / savings, greater number of clinic visits, radiographs, magnetic resonance imaging (MRI) scans, and physical therapy (PT) sessions, and with higher net costs due to clinic visits, radiographs, MRIs, and PT (P < .001). Operative repair at an ambulatory surgical center was associated with a lower net and total payment, and a significantly higher deductible compared to in-hospital settings (P < .001). Both cohorts received similar numbers of opioid prescriptions during the study period. Yet, operative patients had a significantly shorter duration of opioid use. After controlling for confounders, operative repair was also independently associated with lower net costs due to opioid prescriptions. Conclusion Compared with nonoperatively managed ATR, surgical repair is associated with greater costs partially because of greater utilization of clinic visits, imaging, and physical therapy sessions. However, surgical costs may be reduced when procedures are performed in ambulatory surgery centers vs hospital facilities. Nonoperative treatment is associated with higher prescription costs secondary to longer duration of opioid use. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
| | - Arinze J. Ochuba
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Amy L. Xu
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Morgan Snow
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Rachel Bronheim
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Ettore Vulcano
- Mount Sinai Medical Center, Orthopaedic Surgery, Miami, FL, USA
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Diniz P, Ferreira AS, Figueiredo L, Batista JP, Abdelatif N, Pereira H, Kerkhoffs GMMJ, Finkelstein SN, Ferreira FC. Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost-effectiveness profile in the treatment of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2022; 31:2001-2014. [PMID: 36149468 DOI: 10.1007/s00167-022-07146-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective. METHODS A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range. RESULTS For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments. CONCLUSION Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Pedro Diniz
- Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela, 501, 2775-028, Parede, Lisbon, Portugal. .,Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. .,Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. .,Fisiogaspar, Lisbon, Portugal.
| | - André Soares Ferreira
- Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela, 501, 2775-028, Parede, Lisbon, Portugal
| | - Lígia Figueiredo
- Clinical Department Club Atletico Boca Juniors, CAJB Centro Artroscopico, Buenos Aires, Argentina
| | - Jorge Pablo Batista
- Head of Orthopedic Department, Dr Nasef OrthoClinic, Private Practice, Cairo, Egypt
| | - Nasef Abdelatif
- Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila Do Conde, Portugal
| | - Hélder Pereira
- Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia/Madrid, Spain.,PT Government Associate Laboratory, University of Minho ICVS/3B's, Braga/Guimarães, Portugal.,Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam University Medical Centers, Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
| | - Gino M M J Kerkhoffs
- Institute for Data, Systems and Society, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Stan N Finkelstein
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Bioceramed - Cerâmicos para Aplicações Médicas S.A., Loures, Portugal
| | - Frederico Castelo Ferreira
- Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.,Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
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Ribbans WJ, September AV, Collins M. Tendon and Ligament Genetics: How Do They Contribute to Disease and Injury? A Narrative Review. Life (Basel) 2022; 12:life12050663. [PMID: 35629331 PMCID: PMC9147569 DOI: 10.3390/life12050663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 12/15/2022] Open
Abstract
A significant proportion of patients requiring musculoskeletal management present with tendon and ligament pathology. Our understanding of the intrinsic and extrinsic mechanisms that lead to such disabilities is increasing. However, the complexity underpinning these interactive multifactorial elements is still not fully characterised. Evidence highlighting the genetic components, either reducing or increasing susceptibility to injury, is increasing. This review examines the present understanding of the role genetic variations contribute to tendon and ligament injury risk. It examines the different elements of tendon and ligament structure and considers our knowledge of genetic influence on form, function, ability to withstand load, and undertake repair or regeneration. The role of epigenetic factors in modifying gene expression in these structures is also explored. It considers the challenges to interpreting present knowledge, the requirements, and likely pathways for future research, and whether such information has reached the point of clinical utility.
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Affiliation(s)
- William J. Ribbans
- School of Health, The University of Northampton, Northampton NN1 5PH, UK
- The County Clinic, Northampton NN1 5DB, UK
- Correspondence: ; Tel.: +44-1604-795414
| | - Alison V. September
- Division of Physiological Sciences, Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa; (A.V.S.); (M.C.)
- Health Through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa
- International Federation of Sports Medicine (FIMS), Collaborative Centre of Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7700, South Africa
| | - Malcolm Collins
- Division of Physiological Sciences, Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa; (A.V.S.); (M.C.)
- Health Through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa
- International Federation of Sports Medicine (FIMS), Collaborative Centre of Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7700, South Africa
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9
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Samy AM. Intra-operative ultrasound: does it improve the results of percutaneous repair of acute Achilles tendon rupture? Eur J Trauma Emerg Surg 2022; 48:4061-4068. [PMID: 35275242 PMCID: PMC9532319 DOI: 10.1007/s00068-022-01926-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/20/2022] [Indexed: 12/03/2022]
Abstract
Purpose Percutaneous repair is a good option for acute Achilles tendon rupture. Although it overcomes the complications of open technique, it carries the risk of sural nerve injury and inadequate repair. In this study, we explore if the use of intra-operative ultrasound with percutaneous technique has any advantageous effect on final results of repair. Methods This is a prospective randomized study done between May 2014 and December 2020. It included 91 patients with complete acute Achilles tendon rupture distributed in 2 groups with homogenous clinical and demographic data. Group A (n = 47) included those managed by percutaneous repair with assistant of an intra-operative ultrasound. Group B (n = 44) included those done without the assistant of ultrasound. Post-operative evaluation was done clinically by the American Orthopedic Foot and Ankle Society score, calf muscle circumference and single heel rise test and radiologically by Magnetic Resonance Image. Results Patients of both groups reported continuous improvement of the American Orthopedic Foot and Ankle Society score with time. However, patient of group A recorded better functional outcome score at 3 months postoperatively. We recorded longer operative time in group A than those in group B. Continuous improvement of maximum calf circumference was observed in both groups. Satisfactory healing was noticed to happen faster in patients of group A than those of group B. We recorded two cases of re-rupture and two cases of sural nerve injury in group B with no reported complication in group A. Conclusion The use of an intra-operative ultrasound with percutaneous repair of acute rupture of Achilles tendon can improve the quality of repair as evidenced by quicker satisfactory healing and earlier regain of activity. Also, it can help in proper localization of sural nerve in relation to lateral edge of Achilles tendon. Trial registration Clinical Trials.gov Identifier: NCT04935281.
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10
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Ko PY, Hsu CH, Hong CK, Hung MT, Su WR, Wu PT, Jou IM, Su FC. Jigless knotless internal brace versus other open Achilles tendon repairs using a progressive rehabilitation protocol: a biomechanical study. BMC Musculoskelet Disord 2021; 22:908. [PMID: 34711221 PMCID: PMC8555281 DOI: 10.1186/s12891-021-04809-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The jigless knotless internal brace surgery (JKIB), a modified minimal invasive surgery (MIS) for acute Achilles tendon injury, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as demonstrated in previous clinical research. However, to date, biomechanical testing has not yet been validated. MATERIALS AND METHODS Sixty fresh porcine Achilles tendons were used to compare the JKIB with other open surgery techniques, the four-stranded Krackow suture (4sK) and the triple-bundle suture (TBS) in biomechanical testing with cyclic loading set at 1 Hz. This approach simulated a progressive rehabilitation protocol where 20-100 N was applied in the first 1000 cycles, followed by 20-190 N in the second 1000 cycles, and then 20-369 N in the third 1000 cycles. The cycles leading to repair gaps of 2 mm, 5 mm, and 10 mm were recorded. The survival cycles were defined as repair gap of 10 mm. RESULTS With respect to survival cycles, a significant difference was found among the three groups, in which the TBS was the most robust, followed by the JKIB and the 4sK, where the mean survived cycles were 2639.3 +/- 263.55, 2073.6 +/- 319.92, and 1425.25 +/- 268.96, respectively. Significant differences were verified via a post hoc analysis with the Mann-Whitney U test after the Bonferroni correction (p < 0.017). CONCLUSIONS The TBS was the strongest suture structure in acute Achilles tendon repair. However, the JKIB could be an option in acute Achilles tendon repair with the MIS technique due to it being more robust than the 4sK, which has been typically favored for use in open repair.
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Affiliation(s)
- Po-Yen Ko
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chieh-Hsiang Hsu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Wei-Ren Su
- Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - I-Ming Jou
- Departments of Orthopaedic Surgery and Pathology, E-Da Hospital, I-Shou University, Yen-Chao District, Kaohsiung, Taiwan. .,GEG Orthopedic Clinic, Tainan, Taiwan.
| | - Fong-Chin Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
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11
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McKissack H, McLynn R, Pitts C, Alexander B, Jones J, Andrews NA, Littlefield ZL, Shah A. Safety and Efficacy of Achilles Repair Using the Mini-Open Approach in Supine Versus Prone Position: A Retrospective Study. Cureus 2021; 13:e17564. [PMID: 34646620 PMCID: PMC8480360 DOI: 10.7759/cureus.17564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose Surgical repair of the Achilles tendon is a common procedure in cases of acute rupture. Open Achilles tendon surgery with a traditional extensile approach is most often performed in the prone position, but this can lead to numerous complications. The mini-open approach for repair in the supine position may avoid the risks of the prone position. The purpose of this study is to compare perioperative outcomes and differences in cost between patients undergoing acute Achilles rupture repair with mini-open approach, incision of approximately 3 cm, in the supine position versus traditional approach in the prone position. Methods Patients who underwent surgical repair of acute Achilles rupture at a single institution were retrospectively identified using Current Procedural Terminology (CPT) code 27650. Complication rates and the total cost charged to the insurance companies of both the supine and prone groups were calculated. Results A total of 80 patients were included for analysis, 26 supine and 54 prone. The difference in average total time in the operating room was statistically significant. The prone position took approximately 15% more time (118.7 minutes) compared to the supine position (100 minutes) (p = 0.001). While not statistically significant, the total cost for the supine group ($19,889) was less than the for the prone group ($21,722) (p = 0.153) Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and deep vein thrombosis (DVT) rate were also similar between the two groups. No patient in either group experienced re-rupture of the Achilles tendon within the first year of primary repair. Conclusion The mini-open approach in the supine position may be advantageous in the repair of acute Achilles rupture in that it reduces total time in the operating room and total cost while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.
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Affiliation(s)
- Haley McKissack
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Ryan McLynn
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Charles Pitts
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Bradley Alexander
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - James Jones
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Nicholas A Andrews
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Zachary L Littlefield
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Ashish Shah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
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12
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Caolo KC, Eble SK, Rider C, Elliott AJ, Demetracopoulos CA, Deland JT, Drakos MC, Ellis SJ. Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211060063. [PMID: 35097483 PMCID: PMC8646203 DOI: 10.1177/24730114211060063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques. METHODS A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution's registry. Demographics and complications were recorded. RESULTS PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection). CONCLUSION Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Kristin C. Caolo
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Stephanie K. Eble
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Carson Rider
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Andrew J. Elliott
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Jonathan T. Deland
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mark C. Drakos
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Scott J. Ellis
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
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13
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Naldo J, Agnew P, Brucato M, Dayton P, Shane A. ACFAS Clinical Consensus Statement: Acute Achilles Tendon Pathology. J Foot Ankle Surg 2021; 60:93-101. [PMID: 33199168 DOI: 10.1053/j.jfas.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/29/2020] [Indexed: 02/03/2023]
Abstract
Injuries to the Achilles tendon are a challenge to the foot and ankle surgeon. In recent years, research has led to a relative change in the way that many surgeons view acute Achilles tendon rupture. In an effort to fully evaluate these trends, as well as to evaluate all aspects of care for acute Achilles tendon rupture, the American College of Foot and Ankle Surgeons convened a panel of experts to create a clinical consensus statement to address selected aspects of care of the acute Achilles tendon injury.
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Affiliation(s)
- Jason Naldo
- Chairperson, ACFAS Acute Achilles Tendon Pathology Clinical Consensus Statement, Chicago, IL; Assistant Professor, Department of Orthopaedics, Virginia Tech Carilion School of Medicine, Roanoke, VA; Foot and Ankle Surgeon, Institute for Orthopaedics and Neurosciences, Carilion Clinic, Roanoke, VA.
| | - Patrick Agnew
- Director of Podiatric Medical and Surgical Education, Associate Professor, Eastern Virginia Medical School, Norfolk, VA
| | | | - Paul Dayton
- Private Practice, Foot & Ankle Center of Iowa, Ankeny, IA
| | - Amber Shane
- Chair, Department of Podiatric Surgery, Advent Health System, Orlando, FL; Faculty, Advent Health East Orlando Podiatric Surgical Residency, Orlando, FL
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14
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Gatz M, Driessen A, Eschweiler J, Tingart M, Migliorini F. Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study. Arch Orthop Trauma Surg 2021; 141:383-401. [PMID: 32266518 DOI: 10.1007/s00402-020-03437-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Despite the presence of various different surgical procedures, the preferable technique for repair of acute Achilles tendon ruptures is unknown and, therefore, object of discussions. The purpose of this meta-analysis was to compare clinical outcomes and complication-rates between the minimally invasive and the standard open repair of acute Achilles tendon ruptures. MATERIALS AND METHODS This meta-analysis was performed according to the PRISMA guidelines. In September 2019 the main databases were accessed. All clinical trials of evidence level I to III comparing minimally invasive vs. open surgery of Achilles tendon rupture were included in the present study. Only articles reporting quantitative data under the outcomes of interest were included. Missing data under the outcomes of interest warranted the exclusion from the present work. For the statistical analysis we referred to the Review Manager Software Version 5.3. (The Nordic Cochrane Centre, Copenhagen). Continuous data were analysed through the inverse variance method. For the effect estimate the mean difference was used. Dichotomous data were analysed through the Mante-Haenszel method via odd ratio effect measure. The confidence interval was set at 95% in all the comparisons. Values of P < 0.05 were considered statistically significant. RESULTS A total of 25 articles were included for meta-analysis. The funnel plot revealed poor data dispersion, attesting to this study a low risk of publication bias. The quality of the methodological assessment was moderate. Data from 2223 (1055 open, 1168 minimally invasive) surgical procedures were extracted. The mean follow-up was of 24.29 ± 22.4 months. The open group reported a lower value of post-operative palpable knot at last follow-up and a lower rate of sural nerve palsy. In the minimally-invasive group a shorter surgery duration and a lower rate of post-operative wound necrosis and reduced risk of wound scarring and adhesions has been evidenced. The minimally-invasive cohort detected the lowest values of superficial and deep infections. In both groups no significant difference was shown in re-rupture rate. CONCLUSIONS Compared to the minimally-invasive Achilles tendon reconstruction, the open procedure evidenced a lower rate of sural nerve palsy and postoperative palpable knot, whereas in the minimally-invasive reconstruction group quicker surgery duration, a lower rate of post-operative wound necrosis, superficial and deep infections and less scar tissue adhesions could be observed. No relevant discrepancies were detected among the two techniques in terms of post-operative re-rupture.
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Affiliation(s)
- Matthias Gatz
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Arne Driessen
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
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15
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Liu JY, Duan WF, Shen S, Ye Y, Sun YQ, He W. Achillon versus modified minimally invasive repair treatment in acute Achilles tendon rupture. J Orthop Surg (Hong Kong) 2020; 28:2309499020908354. [PMID: 32129145 DOI: 10.1177/2309499020908354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To date, the best treatment of acute Achilles tendon rupture (AATR) is still inconclusive. Achillon seems to be a promising approach with satisfactory function and low complication rate. We hypothesize a modified minimally invasive repair (MMIR), which provides direct visualization of proximal tendon stump without specialized equipment that could provide comparable results. This trial is aimed to evaluate the functional and surgical outcomes of MMIR comparing with Achillon. METHODS From February 2013 to February 2017, 114 patients with AATR were enrolled in this trial, underwent an alternative operation (Achillon or MMIR), and accelerated rehabilitation protocol. Forty-four patients took the Achillon and the other 70 patients took the MMIR at their subjective choice. One hundred eleven full follow-up data were obtained including Achilles tendon total rupture score (ATRS), time back to work, rerupture rate, overall complication rate, and operation time. RESULTS There was no significant difference between groups in demographic characters. There was no statistical difference between both groups regarding to time return to work and ATRS at 3rd, 6th, 12th, and 24th month, respectively. Five reruptures and two Achilles tendons tethering to skins were found in the Achillon group, and two reruptures and one sural nerve injury in the MMIR group. No wound infection and dehiscence occurred. Overall complication rate in the Achillon group is higher (16.3% vs. 4.4%, p = 0.044). The operation time of Achillon is less than MMIR (34.84 vs. 39.71, p < 0.001). CONCLUSION Both techniques combining with accelerated rehabilitation showed to be reliable and effective. MMIR is safer and more economical, and Achillon is faster.
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Affiliation(s)
- Jun-Yi Liu
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.,Orthopedic Trauma Center, Orthopedic Hospital of Henan Province, Zhengzhou, China
| | - Wei-Feng Duan
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.,Orthopedic Trauma Center, Orthopedic Hospital of Henan Province, Zhengzhou, China
| | - Sheng Shen
- Orthopedic Trauma Center, Orthopedic Hospital of Henan Province, Zhengzhou, China
| | - Ye Ye
- Orthopedic Trauma Center, Orthopedic Hospital of Henan Province, Zhengzhou, China
| | - Yong-Qiang Sun
- Orthopedic Trauma Center, Orthopedic Hospital of Henan Province, Zhengzhou, China
| | - Wei He
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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16
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Walsh TP, Merlo GB, Rutter C, Abell B, Platt SR, Arnold JB. Cost-effectiveness of interventions for musculoskeletal foot and ankle conditions: a systematic review. Arthritis Care Res (Hoboken) 2020; 74:626-637. [PMID: 33202113 DOI: 10.1002/acr.24514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/06/2020] [Accepted: 11/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise and synthesise the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions. METHODS Electronic databases were searched for studies presenting economic evaluations of non-surgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35). RESULTS Thirty-six studies were identified reporting non-surgical interventions (n=10), non-surgical versus surgical interventions (n=14) and surgical interventions (n=12). The most common conditions were osteoarthritis, ankle fracture and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the non-surgical alternative. CONCLUSION Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle complaints to best inform future clinical practice guidelines.
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Affiliation(s)
- Tom P Walsh
- Queensland University of Technology (QUT), Faculty of Health, School of Clinical Sciences, Kelvin Grove, Queensland, 4059, Australia
| | - Greg B Merlo
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Herston, Queensland, 4006, Australia
| | - Cameron Rutter
- Queensland University of Technology (QUT), Faculty of Health, University Library, Kelvin Grove, 4059, Australia
| | - Bridget Abell
- Queensland University of Technology (QUT), Centre for Healthcare Transformation, Faculty of Health, Kelvin Grove, Queensland, 4059, Australia
| | - Simon R Platt
- Department of Orthopaedics, Gold Coast University Hospital, Southport, Queensland, 4215, Australia
| | - John B Arnold
- IMPACT in Health, Allied Health & Human Performance, University of South Australia, Adelaide, South Australia, 5000, Australia
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17
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Nilsson N, Nilsson Helander K, Hamrin Senorski E, Holm A, Karlsson J, Svensson M, Westin O. The economic cost and patient-reported outcomes of chronic Achilles tendon ruptures. J Exp Orthop 2020; 7:60. [PMID: 32748273 PMCID: PMC7399724 DOI: 10.1186/s40634-020-00277-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/23/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose While most Achilles tendon ruptures are dramatic and diagnosed quickly, some are missed, with a risk of becoming chronic. A chronic Achilles tendon rupture is defined as a rupture that has been left untreated for more than 4 weeks. By mapping the health economic cost of chronic Achilles tendon ruptures the health-care system might be able to better distribute resources to detect these ruptures at an earlier time. Method All patients with a chronic Achilles tendon rupture who were treated surgically at Sahlgrenska University Hospital or Kungsbacka Hospital between 2013 and 2018 were invited to participate in the study. The patients were evaluated postoperatively using the validated Achilles tendon Total Rupture Score (ATRS). The health-care costs were assessed using clinical records. The production-loss costs were extracted from the Swedish Social Insurance Agency. The cost of chronic Achilles tendon ruptures was then compared with the cost of acute ruptures in a previous study by Westin et.al. Results Forty patients with a median (range) age of 66 (28–86) were included in the study. The mean total cost (± SD) for the patients with a chronic Achilles tendon rupture was 6494 EUR ± 6508, which is 1276 EUR higher than the mean total cost of acute ruptures. Patients with chronic Achilles tendon ruptures reported a mean (min-max) postoperative ATRS of 73 (14–100). Conclusion Missing an Achilles tendon rupture will entail higher health-care costs compared with acute ruptures. Health-care resources can be saved if Achilles tendon ruptures are detected at an early stage.
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Affiliation(s)
- Niklas Nilsson
- 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, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Holm
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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18
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Makulavičius A, Mazarevičius G, Klinga M, Urmanavičius M, Masionis P, Oliva XM, Uvarovas V, Porvaneckas N. Outcomes of open "crown" type v. percutaneous Bunnell type repair of acute Achilles tendon ruptures. Randomized control study. Foot Ankle Surg 2020; 26:580-584. [PMID: 31548150 DOI: 10.1016/j.fas.2019.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/26/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal treatment of acute Achilles tendon ruptures (AATR) is still under debate. The purpose of this study was to evaluate outcomes of open repair comparing with percutaneous procedure for AATR. METHODS 100 patients with AATR were randomized in two groups: open "crown" type (group A) and percutaneous Bunnell type repair (group B). 87 patients were available for the mean follow up of 27months RESULTS: No statistically significant difference was observed between groups in ATRS score, leg circumference, single heel rise, Achilles resting angle, time back to work and sports and overall patient satisfaction. Percutaneous technique was much faster. Overall 13 complications occurred in both groups (5 and 8 respectively). No deep infection occurred, no revisions were needed. CONCLUSIONS Both techniques showed to be effective and safe when using absorbable suture material with a high patient satisfaction and a low complication rate, but percutaneous repair was significantly faster.
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Affiliation(s)
- Aleksas Makulavičius
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania.
| | - Giedrius Mazarevičius
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Mindaugas Klinga
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Matas Urmanavičius
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Povilas Masionis
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Xavier Martin Oliva
- Barcelona University, Faculty of Medicine, Department of Embriology and Human Anatomy, Barcelona, Spain
| | - Valentinas Uvarovas
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Narūnas Porvaneckas
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
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19
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Su AW, Bogunovic L, Johnson J, Klein S, Matava MJ, McCormick J, Smith MV, Wright RW, Brophy RH. Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Pilot Economic Decision Analysis. Orthop J Sports Med 2020; 8:2325967120909918. [PMID: 32284940 PMCID: PMC7139191 DOI: 10.1177/2325967120909918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/17/2019] [Indexed: 11/15/2022] Open
Abstract
Background The operative treatment of Achilles tendon ruptures has been associated with lower rerupture rates and better function but also a risk of surgery-related complications compared with nonoperative treatment, which may provide improved outcomes with accelerated rehabilitation protocols. However, economic decision analyses integrating the updated costs of both treatment options are limited in the literature. Purpose To compare the cost-effectiveness of operative and nonoperative treatment of acute Achilles tendon tears. Study Design Economic and decision analysis; Level of evidence, 2. Methods An economic decision model was built to assess the cost-utility ratio (CUR) of open primary repair versus nonoperative treatment for acute Achilles tendon ruptures, based on direct costs from the practices of sports medicine and foot and ankle surgeons at a single tertiary academic center, with published outcome probabilities and patient utility data. Multiway sensitivity analyses were performed to reflect the range of data. Results Nonoperative treatment was more cost-effective in the average scenario (nonoperative CUR, US$520; operative CUR, US$1995), but crossover occurred during the sensitivity analysis (nonoperative CUR range, US$224-US$2079; operative CUR range, US$789-US$8380). Operative treatment cost an extra average marginal CUR of US$1475 compared with nonoperative treatment, assuming uneventful healing in both treatment arms. The sensitivity analysis demonstrated a decreased marginal CUR of operative treatment when the outcome utility was maximized, and rerupture rates were minimized compared with nonoperative treatment. Conclusion Nonoperative treatment was more cost-effective in average scenarios. Crossover indicated that open primary repair would be favorable for maximized outcome utility, such as that for young athletes or heavy laborers. The treatment decision for acute Achilles tendon ruptures should be individualized. These pilot results provide inferences for further longitudinal analyses incorporating future clinical evidence.
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Affiliation(s)
- Alvin W Su
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA.,Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Ljiljana Bogunovic
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jeffrey Johnson
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Sandra Klein
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jeremy McCormick
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Matthew V Smith
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Rick W Wright
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
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Manent A, López L, Corominas H, Santamaría A, Domínguez A, Llorens N, Sales M, Videla S. Acute Achilles Tendon Ruptures: Efficacy of Conservative and Surgical (Percutaneous, Open) Treatment-A Randomized, Controlled, Clinical Trial. J Foot Ankle Surg 2019; 58:1229-1234. [PMID: 31679677 DOI: 10.1053/j.jfas.2019.02.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 02/03/2023]
Abstract
There is controversy regarding the best treatment for acute ruptures of the Achilles tendon. Multiple treatments present good results in the short and long term, none being superior to the other if a protocol of rehabilitation with full early weightbearing rehabilitation is followed. The objective of this study was to provide evidence on the efficacy and safety of conservative or surgical (percutaneous or open) treatment for acute Achilles tendon rupture. A randomized, controlled, parallel-groups, pilot clinical trial was performed in patients aged ≥18 years who arrived at the emergency room of our center experiencing acute Achilles tendon rupture. Patients were randomized via a computer-generated list to receive 1 of 3 treatments (conservative, percutaneous surgery, or open surgery). All patients followed the same protocol of rehabilitation with early weightbearing. A responder (i.e., successful treatment) was defined as capable of standing heelrise mono- and bipodally for 3 seconds, having a pain score ≤2 (verbal numerical rating scale) after walking, and having returned to active previous life (sport) at 1-year follow-up. From 2014 to 2017, 34 consecutive patients (median age, 41 years [range 18 to 59]; 32 male [94%]) were included: 11 conservative treatment, 11 percutaneous surgery, and 12 open surgery. At 1-year follow-up, the proportion of responders was 100% (11/11, 95% confidence interval [CI] 74% to 100%), 82% (9/11, 95% CI 52% to 95%), and 83% (10/12, 95% CI 55% to 95%), respectively. There was no case of total rerupture. Similar efficacy was found for conservative, percutaneous, and open surgery treatments for acute Achilles tendon rupture at 1-year follow-up with an early weightbearing rehabilitation program.
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Affiliation(s)
- Andrea Manent
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain.
| | - Laia López
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Hèctor Corominas
- Medical Doctor, Rheumatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Alejandro Santamaría
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Alejandro Domínguez
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Natalia Llorens
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Miquel Sales
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Sebastián Videla
- Associate, Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge University Hospital/Bellvitge Biomedical Research Institute/University of Barcelona, L'Hospitalet del Llobregat, Barcelona, Catalonia, Spain
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21
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Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc 2019; 27:2840-2851. [PMID: 30663002 DOI: 10.1007/s00167-018-5295-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE To assess the effects of medical comorbidities on the incidence of surgical site infection following primary Achilles tendon repair. A secondary aim was to assess the effects of specific medical comorbidities on the cost and extent of healthcare utilization related to surgical site infection following primary Achilles tendon repair. METHODS 24,269 patients undergoing primary Achilles tendon repair between 2005 and 2012 were examined. Current Procedural Terminology codes for primary Achilles tendon repair, and incision and drainage were used to search for and compile patient data from the United Healthcare Orthopedic and Medicare databases. Primary outcome measures regarding surgical site infection following primary Achilles tendon repair included the rate of occurrence, cost, and duration of treatment. RESULTS Patients with one or more preexisting medical comorbidities at the time of surgery had an increased rate of surgical site infection compared to those without. Diabetes and vascular complications were associated with the highest surgical site infection rates. The rate of surgical incision and drainage was higher in patients with cardiac arrhythmias and uncomplicated hypertension. The presence of a medical comorbidity significantly increased the cost and duration of surgical site infection treatment. CONCLUSIONS Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. A better understanding of the relationship between each medical comorbidity and surgical site infections following Achilles tendon repair may be ascertained with additional prospective studies, thus, allowing for a more accurate evaluation and stratification of surgical candidates to improve patient outcomes. LEVEL OF EVIDENCE Retrospective cohort study, Level III.
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22
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van Maele M, Misselyn D, Metsemakers WJ, Sermon A, Nijs S, Hoekstra H. Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature. Injury 2018; 49:1947-1952. [PMID: 30144965 DOI: 10.1016/j.injury.2018.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/31/2018] [Accepted: 08/14/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures. METHODS Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved. RESULTS We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant. CONCLUSION The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.
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Affiliation(s)
- Margaux van Maele
- KU Leuven - University of Leuven, Faculty of Medicine, B-3000 Leuven, Belgium
| | - Dominique Misselyn
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - An Sermon
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
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Zappia M, Berritto D, Oliva F, Maffulli N. High resolution real time ultrasonography of the sural nerve after percutaneous repair of the Achilles tendon. Foot Ankle Surg 2018; 24:342-346. [PMID: 29409243 DOI: 10.1016/j.fas.2017.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/13/2017] [Accepted: 03/21/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous Achilles tendon repair has been developed to minimise soft tissue complications following treatment of tendon ruptures. However, there are concerns because of the risk of sural nerve injury. Few studies have investigated the relationship between the Achilles tendon, the sural nerve and its several anatomical course variants. METHODS We studied 7 cadaveric limbs (7 Achilles tendons) in which a percutaneous repair of the Achilles tendon was performed. On each tendon, high resolution real time ultrasonography examination was performed by an experienced musculoskeletal radiologist before and after the procedure, with the surgeons blind to the results of the scan both before and after surgery. RESULTS In two instances, high resolution real time ultrasonography examination revealed nerve entrapment at the level of most proximal lateral suture. CONCLUSIONS Since the sural nerve can be easily visualised using high-frequency high resolution real time ultrasonography, intraoperative ultrasound can be of assistance during percutaneous repair of Achilles tendon rupture. CLINICAL RELEVANCE The sural nerve can be readily visualised by high-frequency high resolution real time ultrasonography probes. It could be beneficial to use high resolution real time ultrasonography intraoperatively or perioperatively to minimise the risks of sural nerve injury when undertaking percutaneous repair of Achilles tendon tears.
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Affiliation(s)
- Marcello Zappia
- Dipartimento di Medicina e di Scienze della Salute, Università degli Studi del Molise, Via De Sanctis 1, 86100, Campobasso, Italy
| | - Daniela Berritto
- Department of Radiology, Private Hospital "Villa Dei Fiori" S.r.l. Accredited to National Health System, Acerra (NA), Italy.
| | - Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | - Nicola Maffulli
- Head of Department of Orthopaedics and Traumatology, Azienda Ospedaliera San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
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Aujla R, Patel S, Jones A, Bhatia M. Predictors of functional outcome in non-operatively managed Achilles tendon ruptures. Foot Ankle Surg 2018; 24:336-341. [PMID: 29409242 DOI: 10.1016/j.fas.2017.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/11/2017] [Accepted: 03/21/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute Achilles tendon (AT) rupture management remains debatable but non-operative functional regimes are beginning to gain popularity. The aim of this study was to identify predictors of functional outcome in patients with AT ruptures treated non-operatively with an immediate weight bearing functional regime in an orthosis. METHODS Analysis of prospectively gathered data from a local database of all patients treated non-operatively at our institution with an AT rupture was performed. For inclusion in the study patients required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 6 months post injury. The ATRS score was correlated against age, gender, time following rupture, duration (8 or 11 weeks) of treatment in a functional orthoses and complications were recorded. RESULTS 236 patients of average age 49.5 years were included. The mean ATRS on completion of rehabilitation was 74 points. The mean ATRS was significantly lower in the 37 females (65.8) as compared to the 199 males (75.6) (p=0.013). Age inversely affected ATRS with a Pearsons correlation of -0.2. There was no significant difference in the ATRS score when comparing the two different treatment regime durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change significantly after 6 months following rupture treatment completion. CONCLUSION Patients with AT ruptures treated non-operatively with a functional rehabilitation regime demonstrate comparable function to other non-surgical regimes with low re-rupture rates. Increasing age and female gender demonstrate inferior functional outcomes. CLINICAL RELEVANCE Females and increasing age predict poorer functional outcome in acute Achilles tendon ruptures managed in a dynamic full-weight bearing treatment regime.
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Affiliation(s)
- Randeep Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | - Shakil Patel
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Annette Jones
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
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25
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Carmont MR. Achilles tendon rupture: the evaluation and outcome of percutaneous and minimally invasive repair. Br J Sports Med 2018; 52:1281-1282. [DOI: 10.1136/bjsports-2017-099002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/04/2022]
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Manent A, Lopez L, Vilanova J, Mota T, Alvarez J, Santamaría A, Oliva XM. Assessment of the Resistance of Several Suture Techniques in Human Cadaver Achilles Tendons. J Foot Ankle Surg 2018; 56:954-959. [PMID: 28842104 DOI: 10.1053/j.jfas.2017.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 02/03/2023]
Abstract
Many treatments are available for acute Achilles tendon ruptures, conservative and surgical, with none superior to another. For surgical treatment, one can use various techniques. Recent studies have shown that double stitches are superior to simple sutures. Therefore, in the present study, we sought to determine the suture technique that is the most resistant to rupture. We performed an experimental anatomic study with 27 fresh-frozen human cadaveric Achilles tendons obtained through the body donation program of the University of Barcelona, testing the maximum strength. We simulated a rupture by performing resection in the middle portion of the tendon, 4 cm proximal to the calcaneus insertion. We then evaluated the double Kessler, double Bunnell, Krackow, and percutaneous Ma and Griffith technique. We used absorbable suture (polydioxanone no. 1) with all the techniques. Traction was performed using a machine that pulls the tendon at 10 to 100 N in 1000 repetitive cycles. Statistical analysis was performed using the χ2 test and analysis of variance, with the 95% confidence intervals (p < .05). All repairs failed at the site of the suture knots, with none pulling out through the substance of the tendon. We found no significant differences among the different open suture techniques (p > .05). The Krackow suture presented with superior resistance, with a rupture rate 16.70% but with a mean elongation of 7.11 mm. The double Bunnell suture had the same rupture rate as the Krakow suture (16.70%) but with an inferior mean elongation of 4.53 mm. The Krackow and Bunnell suture were superior in endurance, strength of failure, and primary stability compared with the other suture types. However, the former presented with greater tendon elongation, although the difference was not statistically significant. Therefore, according to our findings and the published data, we recommend double Bunnell sutures for the surgical treatment of acute Achilles tendon rupture.
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Affiliation(s)
- Andrea Manent
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain.
| | - Laia Lopez
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Vilanova
- Surgeon in Practice, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Tiago Mota
- Intern, Department of Anatomy, Universitat de Barcelona (H. Clinic), Barcelona, Spain
| | - Jordi Alvarez
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Alejandro Santamaría
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Martí Oliva
- Orthopedic Surgeon and Professor, Department of Anatomy, Universitat de Barcelona, Barcelona, Spain
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Becher C, Donner S, Brucker J, Daniilidis K, Thermann H. Outcome after operative treatment for chronic versus acute Achilles tendon rupture - A comparative analysis. Foot Ankle Surg 2018; 24:110-114. [PMID: 29409231 DOI: 10.1016/j.fas.2016.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/10/2016] [Accepted: 12/11/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study compared outcomes after treatment of acute Achilles tendon (AT) rupture via percutaneous suturing, with those after chronic AT rupture treated via open reconstruction. METHODS This retrospective study included 30 patients who underwent either percutaneous suturing for acute AT rupture (group AR, n=16) or open reconstruction for chronic AT rupture (group CR, n=14). Function was evaluated by calf muscle circumference, and endurance through isokinetic measurement and single-leg heel-rise test. Score evaluation included AT Total Rupture Score, Victorian Institute of Sports Assessment-Achilles questionnaire, and visual analogue scale pain score. Postoperative tendon thickness was measured using ultrasonography and MRI. RESULTS Follow-up was conducted 4.97±1.79 years postoperatively. The groups were similar in age and body mass index. There was no significant difference between groups in calf circumference, isokinetic measurement, heel-rise test, and score evaluation. There was significantly less mediolateral tendon thickening in group AR compared with group CR on ultrasonography (p=0.01) and MRI (p=0.001). CONCLUSIONS Open reconstruction for chronic AT rupture may result in comparable clinical and functional outcomes, but a thicker tendon compared with percutaneous suturing after acute AT rupture.
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Affiliation(s)
- C Becher
- International Center for Hip-, Knee- and Foot Surgery, ATOS Clinic, Heidelberg, Germany.
| | - S Donner
- St. Josefs Hospital, Wiesbaden, Germany
| | - J Brucker
- International Center for Hip-, Knee- and Foot Surgery, ATOS Clinic, Heidelberg, Germany
| | | | - H Thermann
- International Center for Hip-, Knee- and Foot Surgery, ATOS Clinic, Heidelberg, Germany
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28
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Westin O, Svensson M, Nilsson Helander K, Samuelsson K, Grävare Silbernagel K, Olsson N, Karlsson J, Hansson Olofsson E. Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2018; 26:3074-3082. [PMID: 29696317 PMCID: PMC6154020 DOI: 10.1007/s00167-018-4953-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE An Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture. METHODS One hundred patients (86 men, 14 women; mean age, 40 years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical n = 49, non-surgical n = 51). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient's injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping. RESULTS Pre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management (p = 0.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY. CONCLUSIONS Surgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Nicklas Olsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Elisabeth Hansson Olofsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg, Sweden
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Abstract
BACKGROUND Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture. METHODS We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury. RESULTS Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost. CONCLUSION From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management. LEVEL OF EVIDENCE III, Economic Decision Analysis.
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30
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Zayni R, Coursier R, Zakaria M, Desrousseaux JF, Cordonnier D, Polveche G. Activity level recovery after acute Achilles tendon rupture surgically repaired: a series of 29 patients with a mean follow-up of 46 months. Muscles Ligaments Tendons J 2017; 7:69-77. [PMID: 28717614 DOI: 10.11138/mltj/2017.7.1.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Achilles tendon rupture is a common injury but its optimal management is still controversial. When decided, surgical repair can be performed by open or percutaneous techniques. Till now, there is no agreement on the ideal type of surgical management. PURPOSE To compare the outcomes of the percutaneous and open surgical treatment for acute Achilles tendon rupture and to assess the postoperative activity level recovery. METHODS Between 2008 and 2013, 29 patients were surgically treated for acute Achilles tendon rupture in our institution. 16 patients were operated by percutaneous technique and 13 by open repair. All patients received the same postoperative rehabilitation protocol. Patients were evaluated objectively and subjectively after an average of 46 months (23-91). RESULTS 96.6% of patients had excellent and good results according to subjective assessment. No significant difference was observed with respect to the examined clinical variables between the open and percutaneous repair groups. 20.68% of patients had minor complications related to the operation with lesser complications in the percutaneous group. 89.6% of patients resumed sport activity with an average delay of 7,7 months (4-24) and 57,7% of them resumed at a level equal or superior to their level before injury, with higher rate in the percutaneous group. CONCLUSION Percutaneous technique has similar satisfactory outcomes to open surgery in repairing acute ruptured Achilles tendon with lesser complications and higher activity level recovery rate. LEVEL OF EVIDENCE Retrospective comparative study. Level III.
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Affiliation(s)
- Richard Zayni
- Department of Orthopedic Surgery. Groupe Hospitalier de l'Est de la Meurthe-et-Moselle (GHEMM), France
| | - Raphaël Coursier
- Department of Orthopedic Surgery. Groupement Hospitalier de l'Institut Catholique de Lille (GHICL), France
| | - Moudasser Zakaria
- Department of Orthopedic Surgery. Groupement Hospitalier de l'Institut Catholique de Lille (GHICL), France
| | - Jean-François Desrousseaux
- Department of Orthopedic Surgery. Groupement Hospitalier de l'Institut Catholique de Lille (GHICL), France
| | - Denis Cordonnier
- Department of Orthopedic Surgery. Groupement Hospitalier de l'Institut Catholique de Lille (GHICL), France
| | - Gilles Polveche
- Department of Orthopedic Surgery. Groupement Hospitalier de l'Institut Catholique de Lille (GHICL), France
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Aujla R, Kumar A, Bhatia M. Non-surgical treatment of Achilles rupture: Does duration in functional weight bearing orthosis matter? Foot Ankle Surg 2016; 22:254-258. [PMID: 27810024 DOI: 10.1016/j.fas.2015.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/01/2015] [Accepted: 11/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of acute Achilles tendon ruptures is continually being debated. The success of non-surgical regimes is now evident yet there remains a high rate of surgery in the United States of America and Scandinavia. Recent studies have investigated functional outcome rather than complication rates as primary outcome but the current data are still sparse. We aimed to investigate whether there is any difference in functional outcomes between two dynamic regimes of differing durations for acute Achilles tendon ruptures. METHODS The patients in the two groups were matched for age, gender, follow-up duration and mechanism of injury. Forty-four patients were managed in a regime of 11 weeks and another 44 patients for 8 weeks. Demographics, injury details, complications and functional outcome were recorded. The validated Achilles Tendon Rupture Score (ATRS) was used to assess functional outcomes. Minimum follow-up was 1 year. RESULTS The 11-week group had a mean age of 50.8 years (range: 27-80) with 36 (82%) males. The 8-week group had a mean age of 52.0 years (range: 32-77) with 36 (82%) males. The mean ATRS for the 11-week group was 76.0 (range: 8-100). The mean ATRS for the 8-week group was 76.1 (range: 30-100). There were no re-ruptures in the 11-week group and one in the 8-week group. There were three episodes of venous thromboembolism in the 11-week group and four in the 8-week group. CONCLUSION A reduction in duration of dynamic rehabilitation for non-operative treatment of Achilles tendon rupture from 11 weeks to 8 weeks does not lead to a significant detriment in functional outcomes or complication rates.
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Affiliation(s)
- Randeep Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | - Amit Kumar
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
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Li Q, Wang C, Huo Y, Jia Z, Wang X. Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review of overlapping meta-analyses. J Orthop Surg Res 2016; 11:65. [PMID: 27266275 PMCID: PMC4893828 DOI: 10.1186/s13018-016-0401-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/01/2016] [Indexed: 01/05/2023] Open
Abstract
Background A number of meta-analyses have been carried out to evaluate the effects of minimally invasive surgery (MIS) versus open surgery (OS) for acute Achilles tendon rupture. However, discordant findings were seen in these meta-analyses. The present study, performing a systematic review of overlapping meta-analyses regarding MIS versus OS of acute Achilles tendon rupture, aimed to assist decision-makers interpret and choose among conflicting meta-analyses, as well as to offer treatment recommendations based on current best evidence. Methods The literature search was performed to identify systematic reviews comparing MIS with OS for Achilles tendon rupture. Meta-analyses only comprising randomized controlled trials (RCTs) were included. Two authors individually evaluated the quality of meta-analysis and extracted data. The Jadad decision algorithm was conducted to ascertain which meta-analysis offered the best evidence. Results A total of four meta-analyses was included. All these meta-analyses comprised RCTs or quasi-RCTs and were determined as Level-II evidence. The scores of the Assessment of Multiple Systematic Reviews (AMSTAR) ranged from 7 to 10 (median 9.5). The Jadad algorithm indicated that the best meta-analysis should be chosen according to the search strategies and application of selection. A high-quality meta-analysis with more RCTs was chosen, which suggested that there was no statistically significant difference between MIS and OS regarding rerupture rate, tissue adhesion, sural nerve injury, deep infection, and deep vein thrombosis. However, MIS could decrease superficial infection rate, and had a better patient satisfaction for good to excellent outcomes in comparison to OS. Conclusions Based on the best available evidence, MIS may be superior to OS for treating acute Achilles tendon rupture. However, due to some limitations, this should be cautiously interpreted, and further high-quality studies are needed.
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Affiliation(s)
- Qingbo Li
- Department of Orthopaedic Trauma, The Second Hospital of Shandong University, Jinan, People's Republic of China
| | - Chuanying Wang
- Department of Rehabilitation, The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, No.1 Jingba Road, Jinan, 250001, People's Republic of China.
| | - Yanqing Huo
- Department of Orthopaedic Trauma, The Second Hospital of Shandong University, Jinan, People's Republic of China
| | - Zhiwei Jia
- Department of Orthopaedics, The 306th Hospital of People's Liberation Army, Beijing, People's Republic of China.
| | - Xiqian Wang
- Department of Orthopaedic Trauma, The Second Hospital of Shandong University, Jinan, People's Republic of China
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Ververidis AN, Kalifis KG, Touzopoulos P, Drosos GI, Tilkeridis KE, Kazakos KI. Percutaneous repair of the Achilles tendon rupture in athletic population. J Orthop 2016; 13:57-61. [PMID: 26955226 DOI: 10.1016/j.jor.2015.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/08/2015] [Indexed: 11/18/2022] Open
Abstract
AIMS This review was designed in order to study the percutaneous repair of Achilles tendon rupture in athletic population. We present a comprehensive description of clinical, functional outcomes, complications, with emphasis on patients' level, and time of return to sports. METHODS We proceeded to a systematic search of Medline (PubMED), Cochrane, and Scopus databases using keywords "Achilles Tendon", "Percutaneous Repair", "Percutaneous suturing", "Subcutaneous repair", "Subcutaneous suturing", "Athletes", and "Athletic" to identify articles or abstracts written in English. RESULTS Thirteen studies, including 670 patients, could be identified. A variety of percutaneous repair techniques were performed. Re-rupture rate was very low. The most frequent complication was sural nerve damage. Average functional outcomes were satisfying. Up to 91.4% continued practicing sports after surgery. Furthermore, 78-84% returned to the same or higher sports level. Average time of return was 18 weeks in 9 studies. CONCLUSION Percutaneous repair of Achilles tendon rupture is an excellent perspective for athletic population. Low re-rupture rate and impressing level of return to sports allow athletes to continue their recreational activities or careers.
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Affiliation(s)
- Athanasios N Ververidis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece
| | - K Georgios Kalifis
- Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece
| | | | - Georgios I Drosos
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece
| | - Konstantinos E Tilkeridis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece
| | - Konstantinos I Kazakos
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece
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Abstract
The incidence of acute Achilles tendon ruptures is on the rise. This is thought to be due to the increasing number of middle-aged persons participating in athletic and/or strenuous activity. Ruptures of the Achilles tendon can be severely debilitating, with deficits seen years after the initial incident. Also, these injuries can have substantial socioeconomic impacts regardless of the treatment selected. Debate continues over the optimal treatment of Achilles tendon ruptures, especially the argument whether to treat patients nonoperatively or surgically. Newer evidence shows that functional rehabilitation, including early weight-bearing, should be an integral part of successful treatment of acute Achilles ruptures. Further research is needed to further investigate the ideal treatment and rehabilitation protocols.
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Affiliation(s)
- David Pedowitz
- />Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Greg Kirwan
- />Premier Orthopaedics, Chester County Orthopaedic Associates, 915 Old Fern Hill Road, (Suite 1 B-A), West Chester, PA 19380 USA
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Karabinas PK, Benetos IS, Lampropoulou-Adamidou K, Romoudis P, Mavrogenis AF, Vlamis J. Percutaneous versus open repair of acute Achilles tendon ruptures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:607-13. [PMID: 24190345 DOI: 10.1007/s00590-013-1350-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/18/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Controversy exists regarding the optimal treatment for acute Achilles tendon ruptures. Conservative and surgical treatments have been reported with variable results and complications rates. The purpose of this study is to compare the postoperative clinical and functional results of percutaneous versus open repair of acute Achilles tendon ruptures. MATERIALS AND METHODS We present 34 patients with acute Achilles tendon ruptures treated with open and percutaneous surgical repair. There were 15 patients who had open surgical repair and 19 patients who had percutaneous repair. The mean follow-up was 22 months (range 10-24 months) for the open repair group and 20 months (range 9-24 months) for the percutaneous repair group; no patient was lost to follow-up. Postoperative rehabilitation was the same for both groups. Wound healing, complications, ankle range of motion, and patients' return to work, activity level, weight-bearing, and subjective assessment of their treatment were recorded. RESULTS No significant difference was observed with respect to any of the examined variables between the open and percutaneous repair groups. Tendon healing was observed in all patients of both groups by 7-9 weeks. The mean time of patients' return to work was 7 weeks for the open repair group and 9 weeks for the percutaneous repair group. All patients were capable of full weight bearing by the 8th postoperative week time; the time to return to previous activities including non-contact sports was 5 months for both groups. All patients expressed satisfaction and graded their treatment as good. As expected, cosmetic appearance was significantly better in the percutaneous repair group. One patient who had open repair experienced skin incision pain and dysesthesia and graded his operation as fair. No patient experienced other complications such as re-rupture, infection, sural neuroma, or Achilles tendinitis within the period of this study. CONCLUSIONS The present study showed similarly successful clinical and functional results after both open and percutaneous repair of acute Achilles tendon ruptures are similar. Cosmetic appearance is superior in the group of patients who had a percutaneous treatment.
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