Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia

Achilles Tendon Reconstruction with Semitendinous Tendon Grafts Is Associated with a High Complication Rate

BACKGROUND

In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation.

METHODS

We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016.

RESULTS

During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22-180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient).

CONCLUSIONS

In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.

Augmented Versus Nonaugmented Repair of Acute Achilles Tendon Rupture: A Systematic Review and Meta-analysis

BACKGROUND

Although simple end-to-end repair of the Achilles tendon is common, many augmented repair protocols have been implemented for acute Achilles tendon rupture. However, whether augmented repair is better than nonaugmented repair of an acute Achilles tendon rupture is still unknown.

PURPOSE

To conduct a meta-analysis to determine whether augmented surgical repair of an acute Achilles tendon rupture improved subjective patient satisfaction without an increase in rerupture rates. Secondary outcomes assessed included infections, ankle range of motion, calf muscle strength, and minor complications.

STUDY DESIGN

Meta-analysis.

METHODS

A systematic literature search of peer-reviewed articles was conducted to identify all randomized controlled trials (RCTs) comparing augmented repair and nonaugmented repair for acute Achilles tendon rupture from January 1980 to August 2016 in the electronic databases of PubMed, Web of Science (SCI-E/SSCI/A&HCI), and EMBASE. The keywords (Achilles tendon rupture) AND (surg* OR operat* OR repair* OR augment* OR non-augment* OR end-to-end OR sutur*) were combined, and results were limited to human RCTs and controlled clinical trials published in the English language. Four RCTs involving 169 participants were eligible for inclusion; 83 participants were treated with augmented repair and 86 were treated with nonaugmented repair.

RESULTS

Augmented repair led to similar responses when compared with nonaugmented repair for acute Achilles tendon rupture (93% vs 90%, respectively; P = .53). The rerupture rates showed no significant difference for augmented versus nonaugmented repair (7.2% vs 9.3%, respectively; P = .69). No differences in superficial and deep infections occurred in augmented (7 infections) and nonaugmented (8 infections) repair groups during postoperative follow-up ( P = .89). The average incisional infection rate was 8.4% with augmented repair and 9.3% with nonaugmented repair. No significant differences in other complications were found between augmented (7.2%) and nonaugmented (8.1%) repair ( P = .80).

CONCLUSION

Augmented repair, when compared with nonaugmented repair, was not found to improve patient satisfaction or reduce rerupture rate or infection rate. These conclusions are based on 4 trials with small sample sizes, and larger randomized trials are required to confirm these results.

Treatment of midportion Achilles tendinopathy: an evidence-based overview

In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made.

LEVEL OF EVIDENCE

IV.

Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up

BACKGROUND

This prospective randomized trial with a mean fourteen-year follow-up compared simple end-to-end repair with fascial flap-augmented repair for acute Achilles tendon ruptures.

METHODS

From 1998 to 2001, sixty patients with acute Achilles tendon rupture were randomized to receive simple end-to-end repair or augmented repair; both groups were treated with postoperative bracing allowing free active plantar flexion. After a follow-up of thirteen years or more, fifty-five patients (twenty-eight in the nonaugmented-repair group and twenty-seven in the augmented-repair group) were reexamined. Outcome measures included the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey.

RESULTS

After a mean of fourteen years of follow-up, the mean Leppilahti score was 87.1 points for the nonaugmented repairs and 91.5 points for the augmented repairs, with a mean difference of 4.3 points (95% confidence interval [CI], -0.1 to 8.8 points). The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the nonaugmented repairs and 107.3 Nm after the augmented repairs (mean difference, 5.3 Nm [95% CI, -22.2 to 11.6 Nm]) and a median work-displacement deficit of 6.7% to 20.3% after the nonaugmented repairs and 12.8% to 18.0% after the augmented repairs (p = 0.9). Strength did not significantly change between the twelve-month and fourteen-year follow-up examinations. At a mean of fourteen years, the injured side showed a 12.2% to 18.0% median work-displacement deficit compared with the unaffected side (p < 0.001). RAND-36 scores indicated no between-group difference in health domains.

CONCLUSIONS

Augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair. Achilles tendon ruptures result in a permanent calf muscle strength deficit, but its clinical relevance remains unclear.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Achilles tendon: functional anatomy and novel emerging models of imaging classification

PURPOSE

Ideally, a classification should have some prognostic value, and should therefore include precise information upon extent and location of the Achilles tendon disorders. We propose a new imaging and anatomical system to classify Achilles tendon disorders at imaging using US and MRI.

APPROACH

We consider the non-insertional region as the tendon mid-portion, and distinguish the insertional component into a pre-insertion site, located about two centimetres above the calcaneum, and a calcaneal insertion, where the tendon is attached to the bone. On sagittal scans, we introduced a new classification which considers two main portions: "musculotendinous" and "insertional". In the context of the muscolotendinous portion, it is possible to find muscle fibres proximally, and the free tendon distally. This latter is made up of proximal, middle and distal portions. We also propose a 5 grade Doppler classification system to quantify blood flow, in which Grades I and II are respectively characterised by the presence of one and two vessels within the tendon; in Grades III, IV and V, the neovascularisation respectively involves less than 50 %, from 50 to 90 %, and more than 90 % of the tendon tissue. These proposed systems will require validation and possible modification to be applied to different tendons.

Favorable outcome of percutaneous repair of achilles tendon ruptures in the elderly

Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65 years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4 +/- 8.7 years (range, 65-86 years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49 months (mean, 88 months; range, 49-110 months). The ATRS had a postoperative average rating of 69.4 +/- 14 (range, 56-93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures

We prospectively analyzed the functional and clinical results of patients who underwent a single end-to-end suture and an augmented tendon repair with plantaris tendon at middle-term follow-up. From January 2003 to May 2005, 30 consecutive patients were operated on for the treatment of acute Achilles' tendon rupture by means of 2 different methods. No cases required adjunctive procedures to allow for acceptable end-to-end apposition. All ruptures were acute and repairable. The patients were divided into 2 groups. In group 1, augmentation with plantaris tendon was performed in addition to the Krakow end-to-end suturing technique in 16 patients, and in group 2, only the Krakow end-to-end suturing technique was used in 14 patients. The average age of the patients was 40.6 years. Patients in the study groups were followed up at a mean of 17.8 months after surgery. At the end of the follow-up, functional and subjective outcome scores were evaluated. The American Orthopaedic Foot and Ankle Society hindfoot clinical outcome scores were 96.7 in group 1 and 98.8 in group 2. Although there was a numerical increase in group 2, no significant difference was determined between the 2 study groups statistically. The surgical outcome concerning local tenderness, skin adhesion scar, and tendon thickness was better in group 2 than in group 1 without a statistical significance. Although functional outcomes of both treatment groups were the same, the end-to-end suturing technique provided a safer and more reliable treatment with a low risk of complications in the treatment of acute Achilles' tendon ruptures compared with the plantaris tendon augmentation technique.