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Saab M, Beldame J, Charpail C, Kaba A, Mainard D, Caubère A, Maynou C, Bredicianu R, Ghorbani A, Giunta JC, Coursier R, Thoreux P, Laboute E. Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year. Orthop Traumatol Surg Res 2024; 110:103886. [PMID: 38615885 DOI: 10.1016/j.otsr.2024.103886] [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: 11/13/2022] [Revised: 11/28/2023] [Accepted: 02/02/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results. HYPOTHESES There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols. METHODS This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review. RESULTS Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07). CONCLUSIONS This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes. LEVEL OF EVIDENCE III; retrospective comparative, non-randomized.
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Affiliation(s)
- Marc Saab
- Service d'orthopédie 1-traumatologie, CHU de Lille, 59000 Lille, France.
| | - Julien Beldame
- Institut de la cheville et du pied, clinique Blomet, 75015 Paris, France; Clinique Megival, 76550 Saint-Aubin-sur-Scie, France
| | - Christel Charpail
- SOS pied-cheville, clinique du sport, 33700 Merignac, France; Centre Achille, 34070 Montpellier, France
| | - Arnaud Kaba
- Centre hospitalier de Dunkerque, 130, avenue Louis-Herbeaux, 59240 Dunkerque, France
| | - Didier Mainard
- CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - Alexandre Caubère
- Hôpital d'instruction des armées Saint-Anne, 2, boulevard Saint-Anne, 83000 Toulon, France
| | - Carlos Maynou
- Service d'orthopédie 1-traumatologie, CHU de Lille, 59000 Lille, France
| | - Rares Bredicianu
- Centre hospitalier de Sarrebourg, 25, avenue General-de-Gaulle, 57400 Sarrebourg, France
| | - Ali Ghorbani
- Medipole Garonne, 45, rue de Gironis, 31036 Toulouse, France
| | | | - Raphaël Coursier
- Hôpital Saint-Vincent, boulevard de Belfort, 59000 Lille, France
| | - Patricia Thoreux
- Hôpital Hôtel-Dieu-APHP-université Sorbonne Paris Nord, 75004 Paris, France
| | - Eric Laboute
- CERS, groupe Ramsay Santé, 83, avenue du Maréchal-de-Lattre-de-Tassigny, 40130 Capbreton, France
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Hong CC, Seow D, Koh JH, Rammelt S, Pearce CJ. Paratenon preserving repair of the midsubstance acute Achilles tendon rupture: a systematic review and meta-analysis with best- and worst-case analyses for rerupture rates. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05486-0. [PMID: 39153101 DOI: 10.1007/s00402-024-05486-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 06/12/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR. MATERIALS AND METHODS A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I2 < 25% (low heterogeneity), and random effects models were employed if I2 ≥ 25% (moderate to high heterogeneity). RESULTS The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%. CONCLUSIONS Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, 119228, Singapore, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Dexter Seow
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jin Hean Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Stefan Rammelt
- University Center for Orthopaedics & Traumatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Christopher J Pearce
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, 1E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Lawson J, Tarapore R, Sequeira S, Imbergamo C, Tarka M, Guyton G, Hembree W, Gould H. Open and Percutaneous Approaches Have Similar Biomechanical Results for Primary Midsubstance Achilles Tendon Repair: A Meta-analysis. Arthrosc Sports Med Rehabil 2024; 6:100924. [PMID: 39006797 PMCID: PMC11240046 DOI: 10.1016/j.asmr.2024.100924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/06/2024] [Indexed: 07/16/2024] Open
Abstract
Purpose To evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair. Methods A systematic review of original research articles was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. To qualify for study inclusion, articles were required to be published in English, use a laboratory design using either human or animal tissue, and directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique with percutaneous repair using either a locking or nonlocking suture construct. The biomechanical outcomes evaluated were displacement (millimeters) and load to failure (Newtons). Results Twelve studies met inclusion criteria, including 234 specimens (open: 97, percutaneous locking: 73; percutaneous nonlocking: 64) that underwent primary midsubstance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (P = .240) or load to failure (P = .912) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (P = .109) between the locking and nonlocking tendon repair systems. Conclusions The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary midsubstance Achilles tendon repair. Clinical Relevance In clinical studies, similar rerupture rates have been observed after open or percutaneous Achilles tendon repair. It may be beneficial for surgeons to understand whether biomechanical differences exist between these repair techniques.
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Affiliation(s)
- Jonathan Lawson
- Georgetown University School of Medicine, Washington, DC, U.S.A
| | - Rae Tarapore
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, U.S.A
| | - Sean Sequeira
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, U.S.A
| | - Casey Imbergamo
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, U.S.A
| | - Mitchell Tarka
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, U.S.A
| | - Gregory Guyton
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, U.S.A
| | - Walter Hembree
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, U.S.A
| | - Heath Gould
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, U.S.A
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Savage-Elliott I, Li ZI, Moore MR, Lezak B, Jazrawi T, Golant A, Meislin RJ. No difference in operative time, outcomes, cosmesis, or return to activity and/or sport after minimally invasive versus open repair of primary Achilles ruptures: a retrospective review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1871-1876. [PMID: 38436745 DOI: 10.1007/s00590-024-03859-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/08/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE To compare clinical outcomes and the rate of return to sport among patients that have undergone minimally invasive repair versus open approach of an acute Achilles tendon rupture. METHODS Patients who underwent surgical repair of acute Achilles tendon rupture at a single urban academic institution from 2017 to 2020 with minimum 2-year follow-up were reviewed retrospectively. Preinjury sport participation and preinjury work activity information, the Achilles tendon Total Rupture Score (ATRS), the Tegner Activity Scale, Patient-Reported Outcomes Measurement Information System for mobility and pain interference were collected. RESULTS In total, 144 patients were initially included in the study. Of these, 63 patients were followed with a mean follow-up of 45.3 ± 29.2 months. The mean operative time did not significantly differ between groups (p = 0.938). Patients who underwent minimally invasive repair returned to sport at a rate of 88.9% at a mean of 10.6 ± 5.8 months, compared to return rate of open procedures of 83.7% at 9.5 ± 5.5 months. There were no significant differences in ATRS (p = 0.246), Tegner (p = 0.137) or VAS pain (p = 0.317) scores between groups. There was no difference in cosmetic satisfaction between PARS and open repair groups (88.4 vs. 76.0; p = 0.244). CONCLUSION Patients who underwent minimally invasive repair of acute Achilles tendon ruptures demonstrate no significant differences with respect to cosmesis, operative time, patient-reported outcomes and the rate and level of return to activities when compared to an open approach. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ian Savage-Elliott
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Zachary I Li
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Michael R Moore
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA.
| | - Bradley Lezak
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Taylor Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Alexander Golant
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Robert J Meislin
- Department of Orthopedic Surgery, New York University Langone Health, 333 East 38th St, New York, NY, 10016, USA
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Dekker RG, Qin C, Lawton C, Muriuki MG, Havey RM, Alshouli M, Patwardhan AG, Kadakia A. Republication of "A Biomechanical Comparison of Limited Open Versus Krackow Repair for Achilles Tendon Rupture". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231188112. [PMID: 37506092 PMCID: PMC10369101 DOI: 10.1177/24730114231188112] [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: 07/30/2023] Open
Abstract
Background Soft tissue complications after Achilles tendon repair has led to increased interest in less invasive techniques. Various limited open techniques have gained popularity as an alternative to open operative repair. The purpose of this study was to biomechanically compare an open Krackow and limited open repair for Achilles tendon rupture. We hypothesized that there would be no statistical difference in load to failure, work to failure, and initial linear stiffness. Methods A simulated Achilles tendon rupture was created 4 cm proximal to its insertion in 18 fresh-frozen cadaveric below-knee lower limbs. Specimens were randomized to open or limited open PARS Achilles Jig System repair. Repairs were loaded to failure at a rate of 25.4 mm/s to reflect loading during normal ankle range of motion. Load to failure, work to failure, and initial linear stiffness were compared between the 2 repair types. Results The average load to failure (353.8 ± 88.8 N vs 313.3 ± 99.9 N; P = .38) and work to failure (6.4 ± 2.3 J vs 6.3 ± 3.5 J; P = .904) were not statistically different for Krackow and PARS repair, respectively. Mean initial linear stiffness of the Krackow repair (17.8 ± 5.4 N/mm) was significantly greater than PARS repair (11.8 ± 2.5 N/mm) (P = .011). Conclusion No significant difference in repair strength was seen, but higher initial linear stiffness for Krackow repair suggests superior resistance to gap formation, which may occur during postoperative rehabilitation. With equal repair strength, but less soft tissue devitalization, the PARS may be a favorable option for patients with risk factors for soft tissue complications.
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Affiliation(s)
- Robert G Dekker
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Charles Qin
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Cort Lawton
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Muturi G Muriuki
- Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Robert M Havey
- Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL, USA
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maywood, IL, USA
| | - Mohammed Alshouli
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Avinash G Patwardhan
- Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL, USA
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maywood, IL, USA
| | - Anish Kadakia
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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Yang S, Shi W, Yan W, Ao Y, Guo Q, Yang Y. Comparison between primary repair and augmented repair with gastrocnemius turn-down flap for acute Achilles tendon rupture: a retrospective study with minimum 2-year follow-up. BMC Musculoskelet Disord 2023; 24:163. [PMID: 36871017 PMCID: PMC9985193 DOI: 10.1186/s12891-023-06260-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND To explore and compare the clinical outcomes in patients undergoing primary repair versus augmented repair with a gastrocnemius turn-down flap for acute Achilles tendon rupture. METHODS From 2012 to 2018, the clinical data of 113 patients with acute Achilles tendon rupture who were treated with primary repair or augmented repair with a gastrocnemius turn-down flap by the same surgeon were retrospectively reviewed. The patients' preoperative and postoperative scores on the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society Ankle⁃Hindfoot (AOFAS) score, the Victorian Institute of Sport Assessment⁃Achilles (VISA-A), the Achilles tendon total rupture score (ATRS), and the Tegner Activity Scale were examined and compared. The postoperative calf circumference was measured. A Biodex isokinetic dynamometer was used to evaluate the plantarflexion strength on both sides. The time to return to life and exercise as well as the strength deficits in both groups were recorded. Finally, the correlation analyses between patient characteristics and treatment details with clinical outcomes were conducted. RESULTS In total, 68 patients were included and completed the follow-up. The 42 and 26 patients who were treated with primary repair and augmented repair were assigned to group A and B, respectively. No serious postoperative complications were reported. No significant between-group differences in any outcomes were observed. It was found that female sex was correlated with poorer VISA-A score (P = 0.009), complete seal of paratenon was correlated with higher AOFAS score (P = 0.031), and short leg cast was correlated with higher ATRS score (P = 0.006). CONCLUSIONS Augmented repair with a gastrocnemius turn-down flap provided no advantage over primary repair for the treatment of acute Achilles tendon rupture. After surgical treatment, females tended to had poorer outcomes, while complete seal of paratenon and short leg cast contributed to better results. LEVEL OF EVIDENCE Cohort study; Level of evidence, 3.
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Affiliation(s)
- Shuai Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Weili Shi
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Wenqiang Yan
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Yingfang Ao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Qinwei Guo
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China.
| | - Yuping Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China.
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Cross AG, Khalil LS, Tomlinson M, Tramer JS, Makhni EC, Cox BA. Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique. Arthrosc Tech 2023; 12:e173-e180. [PMID: 36879876 PMCID: PMC9984726 DOI: 10.1016/j.eats.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/12/2022] [Indexed: 01/21/2023] Open
Abstract
Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.
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Affiliation(s)
- Austin G Cross
- Cox Sports Medicine and Orthopedic Surgery, Mt. Pleasant, Michigan, U.S.A
| | - Lafi S Khalil
- Henry Ford Hospital, Department of Orthopaedic Surgery, Detroit, Michigan, U.S.A
| | - Maggie Tomlinson
- Cox Sports Medicine and Orthopedic Surgery, Mt. Pleasant, Michigan, U.S.A
| | - Joseph S Tramer
- Henry Ford Hospital, Department of Orthopaedic Surgery, Detroit, Michigan, U.S.A
| | - Eric C Makhni
- Henry Ford Hospital, Department of Orthopaedic Surgery, Detroit, Michigan, U.S.A
| | - Benjamin A Cox
- Cox Sports Medicine and Orthopedic Surgery, Mt. Pleasant, Michigan, U.S.A
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Xu L, Jin J, Liu Z, Wu M, Peng B, Jiang J, Liu G, He J, White S, Xia Y. A New Technique of Achilles Tendon Rupture Repaired by Double Transverse Mini-incision to Avoid Sural Nerve Injury: A Consecutive Retrospective Study. Orthop Surg 2022; 15:517-524. [PMID: 36573277 PMCID: PMC9891928 DOI: 10.1111/os.13615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Percutaneous suture is a classic technique used in Achilles tendon repair. However, the complication rates surrounding the sural nerve remain relatively high. Modified percutaneous repair technology can effectively avoid these complications; however, the surgical procedure is complicated. Hence, the present study was conducted to describe a redesigned repair technique for the Achilles tendon able to avoid sural nerve injury and reduce the complexity of the procedure. METHODS Data of patients with acute primary Achilles tendon rupture at our hospital from January 2019 to May 2020 were included. Subjects with expectations for surgical scarring underwent a minimally invasive-combined percutaneous puncture technique. The surgical time, requirement for conversion to other technologies, and length of postoperative hospitalization were investigated to assess efficacy. The American Orthopedic Foot & Ankle Society (AOFAS) score and the Arner-Lindholm scale (A-L scale) were used to assess postoperative clinical outcomes (> 24 months). During the 2-year follow-up, MRI was performed to observe the healing of the Achilles tendon. In addition, subjective satisfaction with surgical scar healing was recorded. RESULTS Twenty consecutive subjects with an average follow-up of 28.3 ± 4.5 months (range, 24-41) met the inclusion criteria. None of the 20 enrolled patients required a converted surgical approach. The mean surgical time was 26.9 ± 6.47 min (range, 20-44). None of the patients experienced dysesthesia or anesthesia around the sural nerve. No signs of postoperative infections were observed. MRI data showed that the wounds of the Achilles tendon healed completely in all the subjects. The AOFAS score increased from 55.6 ± 11.07 (range, 28-71) preoperatively to 97.8 ± 3.34 (range, 87-100) at the last follow-up. The A-L scale showed that 90% of the subjects (n = 18) presented as excellent and 10% of the subjects (n = 2) presented as good, with an excellent/good rate of 100%. Moreover, subjects' satisfaction for surgical scars was 9.1 ± 0.78 (upper limit, 10). CONCLUSIONS The results indicate that this technique can achieve good postoperative function, a small surgical incision, and high scar satisfaction. In addition, this technique should be widely used in suturing Achilles tendon ruptures.
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Affiliation(s)
- Lihu Xu
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
| | - Jiaxin Jin
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
| | - Zhongcheng Liu
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
| | - Meng Wu
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
| | - Bo Peng
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
| | - Jin Jiang
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
| | - Guangyao Liu
- Key Laboratory of Medical Imaging of Gansu ProvinceLanzhou University Second Hospital, Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial IntelligenceLanzhouChina
| | - Jinwen He
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
| | - Sylvia White
- Department of PathologyYale University School of MedicineNew HavenCTUSA
| | - Yayi Xia
- Department of OrthopaedicsLanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu ProvinceLanzhouChina
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Utilizing A Percutaneous Versus Open Achilles Tendon Repair Technique for Treating Acute Achilles Tendon Ruptures in Physically Active Adults: A Critically Appraised Topic. J Sport Rehabil 2022; 31:943-949. [PMID: 35413682 DOI: 10.1123/jsr.2021-0330] [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: 09/13/2021] [Revised: 12/05/2021] [Accepted: 03/02/2022] [Indexed: 11/18/2022]
Abstract
CLINICAL SCENARIO Acute Achilles tendon ruptures can be devastating injuries with the potential to significantly alter an individual's ability to perform functional activities. Given the rise in the incidence of acute Achilles tendon ruptures, it is important to determine whether percutaneous versus open Achilles tendon repair facilitates superior outcomes. CLINICAL QUESTION In physically active adults with an acute Achilles tendon rupture, does performing percutaneous Achilles tendon repair result in improved outcomes compared with open Achilles tendon repair? SUMMARY OF KEY FINDINGS Percutaneous Achilles tendon repair has similar efficacy as open Achilles tendon repair in facilitating return to activity/sport, and demonstrates improvement in short-term functional outcomes with potentially lower wound complication rates. CLINICAL BOTTOM LINE Evidence supports the utilization of percutaneous Achilles tendon repair in physically active adult patients with acute Achilles tendon ruptures. It is important to critically review the benefits, risks, and alternatives of each treatment option based on patient characteristics. In addition, postoperative expectations should be discussed with the patient to set appropriate goals for recovery and improve overall satisfaction. STRENGTH OF RECOMMENDATION A grade B recommendation can be made based on "fair" to "good" evidence from 2 level 2b studies and 1 Level 1b study to support the utilization of percutaneous Achilles tendon repair techniques.
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Dai G, Zheng Y, Lu X, Liu Y, Weng Q, Hong J. The percutaneous oval forceps suture-guiding method with anchor nails for Achilles tendon repair. Injury 2022; 53:1552-1556. [PMID: 35140028 DOI: 10.1016/j.injury.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute Achilles tendon rupture (AATR) is a common injury of the foot and ankle. So far, the optimal management of AATR remains controversial. The target of the present retrospective study was to describe a new operative technique for percutaneous repair of AATR and evaluate efficacy of the technique. METHODS In the present study, 32 patients were enrolled with AATR treated with the percutaneous oval forceps suture-guiding method with anchor nails from Jan 2014 to Jan 2017. The operation duration and length of incision were collected. The functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, Achilles tendon total rupture score (ATRS), range of motion (ROM) of the ankle and plantar flexion strength ratio at the last follow-up. The postoperative sports activity level and complications were also recorded. RESULTS The mean operation duration and length of incision were 24.5 min and 2.0 cm. Whilst patient reported outcome questionnaires like AOFAS and ATRS showed good results, ROM of the ankle was quite low with only 16.5 degrees. Plantar flexion strength ratio was lower post surgery, as well. As for the postoperative sports activity level: 26/32 cases (81.3%) returned to former sports activity level; 4/32 cases (12.5%) showed a decline in sports activity level; 2/32 cases (6.2%) gave up on sports. The overall complication rate was 6.2%, one sural nerve damage and one fusiform thickening were found in the study. CONCLUSION The percutaneous oval forceps suture-guiding method with anchor nails is a new considerable surgery method with adequate healing rates and an alternative to existing surgical procedures.
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Affiliation(s)
- Gaole Dai
- Gaole Dai is affiliated to Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University. Other authors are affiliated to The Second School of Medicine of Wenzhou Medical University, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University.
| | - Yijing Zheng
- Gaole Dai is affiliated to Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University. Other authors are affiliated to The Second School of Medicine of Wenzhou Medical University, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Xiaolang Lu
- Gaole Dai is affiliated to Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University. Other authors are affiliated to The Second School of Medicine of Wenzhou Medical University, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Yang Liu
- Gaole Dai is affiliated to Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University. Other authors are affiliated to The Second School of Medicine of Wenzhou Medical University, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Qihao Weng
- Gaole Dai is affiliated to Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University. Other authors are affiliated to The Second School of Medicine of Wenzhou Medical University, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Jianjun Hong
- Gaole Dai is affiliated to Department of Orthopaedics, The Second Affiliated Hospital of Jiaxing University. Other authors are affiliated to The Second School of Medicine of Wenzhou Medical University, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University.
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Sanada T, Iwaso H, Fukai A, Honda E, Yoshitomi H. Comparison Study of Mini-Incision Versus Original Open Technique of the Half-Mini-Bunnell Achilles Tendon Repair. J Foot Ankle Surg 2022; 61:355-362. [PMID: 34656416 DOI: 10.1053/j.jfas.2021.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 01/30/2021] [Accepted: 02/07/2021] [Indexed: 02/03/2023]
Abstract
Mini-incision surgical procedures in our institution have been developed by decreasing the total skin incision length from the original mini half-Bunnell tendon repair technique. We hypothesized that the mini-incision, or minimum invasive Achilles tendon repair technique, would promote the tendon healing process leading to better outcomes and a reduced complication rate compared to the conventional open repair. The study sought to determine the more optimal method by comparing 44 mini-incision sutures to the 99 sutures in the original open Achilles tendon repairs. The mean skin incision length of the mini-incision surgery was 2.9 (range 2.5-3.0) cm and the original repair was 4.2 (range 3.5-7.0) cm. The mean surgery time was 60.0 minutes in the mini-incision repair and 68.1 minutes in the original one (p = .0003). The mean achievement time of bilateral heel-rise, starting jogging, single-legged heel-rise movement and the time to return-to-play was not significantly different between the 2 groups. Achilles Tendon Rupture Score was not significantly different from 3 to 9 months after surgery. Re-injury rate was 1/44 (2.3%) in mini-incision and 4/99 (4.0%) in conventional open repair (p = .36). No patients in either group developed any postoperative infections nor deep vein thrombosis complications. Although the mini-incision half-mini-Bunnell suture was showed equivalent clinical results to the original open repair, the technique is recommended in terms of curtailment of the surgery time without increase of complication ratio.
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Affiliation(s)
- Takaki Sanada
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan.
| | - Hiroshi Iwaso
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
| | - Atsushi Fukai
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
| | - Eisaburo Honda
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
| | - Hiroki Yoshitomi
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
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12
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Black NR, Chen J, Schweitzer KM. Minimally Invasive Repair of Subacute Achilles Tendon Ruptures: A Report of 2 Cases. Foot Ankle Spec 2022; 16:145-148. [PMID: 35156409 DOI: 10.1177/19386400221076944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Level IV: Case report.
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Affiliation(s)
- Natalie R Black
- School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Jie Chen
- Duke University Medical Center, Raleigh, North Carolina.,Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
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13
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De la Fuente C, Henriquez H, Carmont MR, Huincahue J, Paredes T, Tapia M, Araya JP, Díaz N, Carpes FP. Do the heel-rise test and isometric strength improve after Achilles tendon repair using Dresden technique? Foot Ankle Surg 2022; 28:37-43. [PMID: 33509663 DOI: 10.1016/j.fas.2021.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/11/2021] [Accepted: 01/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Achilles' tendon ruptures result in impaired plantar flexion strength and endurance. It is interesting to know the plantar flexion strength, the number of heel-rise repetitions, and the maximal calf circumference following Achilles' tendon ruptures repair. METHODS Both the injured and non-injured legs of thirty male patients with Achilles' tendon ruptures treated with the percutaneous Dresden technique were compared with the ankle function of 30 healthy participants. Rehabilitation involved partial weight-bearing for three weeks and then increased to full weight-bearing and ankle exercises. RESULTS The injured legs had weaker plantar flexion strength (1.64 ± 0.17 Nm/kg) compared with the non-injured legs (1.91 ± 0.24 Nm/kg; p = 0.002) and the healthy participants' legs (1.93 ± 0.32 Nm/kg; p < 0.001). The non-injured leg had greater ability in doing heel-rise repetitions (39.4 ± 6.1 rep.) compared with the injured legs (37.2 ± 5.7 rep.; p < 0.023) and the healthy participants' legs (31.0 ± 13.0 rep.; p < 0.001). CONCLUSIONS The injured leg had not recovered full isometric strength but had improved heel-rise repetition.
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Affiliation(s)
- Carlos De la Fuente
- Laboratory of Neuromechanics, Universidade Federal do Pampa #97500-970, Campus Uruguaiana, Uruguaiana, Brazil; Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile; Clinica MEDS, Santiago #7691236, Santiago, Chile; Centro de Salud Deportiva, Clinica Santa Maria, Santiago #7520380, Santiago, Chile
| | - Hugo Henriquez
- Centro de Salud Deportiva, Clinica Santa Maria, Santiago #7520380, Santiago, Chile; Traumatologia, Facultad de Medicina, Instituto Traumatológico-Universidad de Chile, Universidad de Chile, Santiago #8340220, Chile
| | - Michael R Carmont
- Department of Trauma and Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust #TF16TF, Shropshire, UK
| | - Javiera Huincahue
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - Tamara Paredes
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - María Tapia
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - Juan Pablo Araya
- Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile #7820244, Santiago, Chile
| | - Nicolás Díaz
- Interno de Medicina, Facultad de Medicina #8340220, Universidad de Chile, Santiago, Chile
| | - Felipe P Carpes
- Laboratory of Neuromechanics, Universidade Federal do Pampa #97500-970, Campus Uruguaiana, Uruguaiana, Brazil.
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14
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Sikorski Ł, Czamara A. Ground Reaction Forces during Vertical Hops Are Correlated with the Number of Supervised Physiotherapy Visits after Achilles Tendon Surgery. J Clin Med 2021; 10:jcm10225299. [PMID: 34830581 PMCID: PMC8620226 DOI: 10.3390/jcm10225299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 12/26/2022] Open
Abstract
The objective of this study was to assess the effectiveness of, and the correlation between, an average of 42 supervised physiotherapy (SVPh) visits for the vertical ground reaction forces component (vGRF) using ankle hops during two- and one-legged vertical hops (TLH and OLH, respectively), six months after the surgical suturing of the Achilles tendon using the open method (SSATOM) via Keesler’s technique. Hypothesis: Six months of supervised physiotherapy with a higher number of visits (SPHNVs) was positively correlated with higher vGRF values during TLH and OLH. Group I comprised male patients (n = 23) after SSATOM (SVPh x = 42 visits), and Group II comprised males (n = 23) without Achilles tendon injuries. In the study groups, vGRF was measured during TLH and OLH in the landing phase using two force plates. The vGRF was normalized to the body mass. The limb symmetry index (LSI) of vGRF values was calculated. The ranges of motion of the foot and circumferences of the ankle joint and shin were measured. Then, 10 m unassisted walking, the Thompson test, and pain were assessed. A parametric test for dependent and independent samples, ANOVA and Tukey’s test for between-group comparisons, and linear Pearson’s correlation coefficient calculations were performed. Group I revealed significantly lower vGRF values during TLH and OLH for the operated limb and LSI values compared with the right and left legs in Group II (p ≤ 0.001). A larger number of visits correlates with higher vGRF values for the operated limb during TLH (r = 0.503; p = 0.014) and OLH (r = 0.505; p = 0.014). An average of 42 SVPh visits in 6 months was insufficient to obtain similar values of relative vGRF and their LSI during TLH and OLH, but the hypothesis was confirmed that SPHNVs correlate with higher relative vGRF values during TLH and OLH in the landing phase.
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Affiliation(s)
- Łukasz Sikorski
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Correspondence: ; Tel.: +48-601-911-013
| | - Andrzej Czamara
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Center of Rehabilitation and Medical Education, 50-038 Wrocław, Poland
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15
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Meulenkamp B, Woolnough T, Cheng W, Shorr R, Stacey D, Richards M, Gupta A, Fergusson D, Graham ID. What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Clin Orthop Relat Res 2021; 479:2119-2131. [PMID: 34180874 PMCID: PMC8445578 DOI: 10.1097/corr.0000000000001861] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery? METHODS This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar. RESULTS We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes. CONCLUSION Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
| | - Taylor Woolnough
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Dawn Stacey
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Megan Richards
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Arnav Gupta
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean Fergusson
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian D. Graham
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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16
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Wei S, Chen J, Kong C, Xu F, Zhi X, Cai X. Endoscopic "internal splinting" repair technique for acute Achilles tendon rupture. Arch Orthop Trauma Surg 2021; 141:1753-1760. [PMID: 33594461 DOI: 10.1007/s00402-021-03818-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/01/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Recently, endoscopically assisted Achilles tendon repair techniques have improved to overcome the surgical complications. However, the risk of sural nerve injury and the strength of repair are still the most concerning aspects. MATERIAL AND METHODS Twenty three patients with acute Achilles tendon rupture were reviewed in the present study. We stitch the Achilles tendon above the ruptured site using the endoscopic locking loop suture technique, and the knotless anchor suture-bridge technique can be used to make the distal fixation of threads. The function was assessed using the muscle power (MRC0-5), ATRS scores, AOFAS ankle-hindfoot scores, and VAS scores at the final follow-up. RESULTS The mean follow-up time was 15.74 ± 2.43 months (12-18). At the final follow-up, the average of the muscle power (MRC0-5), ATRS score, AOFAS ankle-hindfoot score, and VAS score are 4.74 ± 0.45, 97.83 ± 2.77, 96.52 ± 4.87, and 0.35 ± 0.49, respectively. Every patient returned to previous sports activity at 6 months postoperative. No wound infection and sural nerve injuries were encountered. Only one case suffers local irritation at the medial knotless anchor site. CONCLUSIONS Endoscopic "internal splinting" repair for acute Achilles tendon rupture using locking loop stitch with suture-bridge technique leads to an expedited return to activity with a low risk of complications. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Shijun Wei
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China. .,Guangdong, The First Clinical Medical School of Southern Medical University, Guangzhou, People's Republic of China.
| | - Jia Chen
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China
| | - Changwang Kong
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China
| | - Feng Xu
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China. .,Guangdong, The First Clinical Medical School of Southern Medical University, Guangzhou, People's Republic of China.
| | - Xiaosong Zhi
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China
| | - Xianhua Cai
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China.,Guangdong, The First Clinical Medical School of Southern Medical University, Guangzhou, People's Republic of China
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Saxena A, Maffulli N, Jin A, Isa E, Arthur WP, Asthana S. Acute Achilles Tendon Rupture Repair in Athletically Active Patients: Results on 188 Tendons. J Foot Ankle Surg 2021; 60:935-940. [PMID: 33947591 DOI: 10.1053/j.jfas.2021.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 02/03/2023]
Abstract
We report on the outcome of acute Achilles tendon ruptures by a single surgeon using open and percutaneous techniques was performed. This prospective study included 186 patients with 188 ruptured Achilles tendons. A traditional open technique was primarily performed on patients from January 2001 to December 2011. From January 2012 to January 2018, a percutaneous repair was primarily performed. Outcome measures included the Roles and Maudsley (RM) score, ability to perform a single leg heel raise, calf atrophy and return to activity. There were 149 males (average age 42.5 ± 12.7 years) and 39 females (average age 41.7 ± 11.4 years). Of the 188 ruptured tendons (92 repairs on the right Achilles and 96 on the left), 103 were repaired percutaneously and 85 had open repairs. There were 18 (9.6%) complications. Three re-ruptures occurred, one following open and two following percutaneous repairs, all within 12 weeks of the original repair. Two patients developed a Venousthromboembolism (1.0%). Thirteen patients had suture reactions; three infections (1.6%), 11 wound complications (5.8%), and 3 required surgical excision of the suture material (1.6%). Non-absorbable sutures were associated with more wound complications and were more frequently used in open repairs (p = .003). Patients who underwent open repair experienced more wound complications (p = .0001). Patients who underwent percutaneous repair using absorbable suture experienced a lower rate of overall complications (p = .0007). Basketball (n = 29) was the most common sport during which ruptures occurred. Return to activity (RTA) was 8.2 ± 2.9 months. There was no difference for RTA between males and females (p = .54) and RM scores (p= .69), nor surgical technique, and no difference for RTA based on the desired activity (p = .47). 123 of the 188 patients returned to their desired activity (65.5%). There was a statistically significant evidence of a positive association between inability to perform heel-raises and decreased activity (p = .01).
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Affiliation(s)
- Amol Saxena
- Department of Sports Medicine, Sutter-PAMF, Palo Alto, CA.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine, Surgery and Dentistry, Salerno, Italy; Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK; School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, UK
| | - Anqi Jin
- PAMF Research Institute, Researcher, Palo Alto, CA
| | | | | | - Saumya Asthana
- Rosalind Franklin University, Scholl College, Chicago IL
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18
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Xu XY, Gao S, Lv Y, Zhou F, Jiao C, Fan JX, Zhu TJ. Duration of immobilisation after Achilles tendon rupture repair by open surgery: a retrospective cohort study. J Orthop Surg Res 2021; 16:196. [PMID: 33731160 PMCID: PMC7968267 DOI: 10.1186/s13018-021-02342-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/09/2021] [Indexed: 12/28/2022] Open
Abstract
Background The best treatment for acute Achilles tendon ruptures remains controversial. No cohort studies have compared different immobilisation durations after open surgery. This retrospective cohort study aimed to determine the optimal duration of immobilisation after this surgery. Methods A total of 266 patients with acute Achilles tendon rupture were divided into 4 groups (A, B, C, and D) according to immobilisation duration of 0, 2, 4, and 6 weeks, respectively. All patients underwent the same suture technique with a similar rehabilitation protocol and were examined clinically at 2, 4, 6, 8, 10, 12, 14, 16, 24, and 48 weeks, with a final follow-up at a mean of 22.3 months postoperatively. The primary outcome was the time of return to light sports activity (LSA). Secondary outcomes included range of motion (ROM) and single-legged heel rise height (SHRH). Data on operation time, complications, visual analogue pain scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Achilles tendon Total Rupture score (ATRS) were also collected. Demographic baseline data were analysed using one-way analysis of variance; outcome parameters were analysed using Kruskal-Wallis H test, and complications were analysed using Fisher’s exact test. Statistical significance was considered at P ≤ 0.05. Results VAS scores decreased significantly, reaching 0 in all groups after 12 weeks. The AOFAS and ATRS scores were significantly different between the groups from weeks 2 to 12 (P<0.001) and weeks 2 to 16 (P<0.001), respectively. All the mean scores showed better results in group B than in the other groups. In terms of recovery time of ROM, SHRH, and LSA, groups A and B were significantly faster than groups C and D (P<0.001). There were 13 (13/266, 4.9%) complications: 5 superficial infections, 3 deep venous thrombosis, and 5 trauma-related re-ruptures. On the last follow-up, all complications had recovered. There were no significant differences in complications between the groups. Conclusions Immobilisation for 2 weeks after this open surgery is the best choice for early rehabilitation and weight-bearing while minimising pain and other complications.
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Affiliation(s)
- Xiang Yu Xu
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Shan Gao
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Yang Lv
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China.
| | - Fang Zhou
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China.
| | - Chen Jiao
- Department of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Ji Xing Fan
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Teng Jiao Zhu
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
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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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Bryant SA, Trang G, Nash HM, Gardner BB, Kim JY, Park HY, Chakrabarti M, McGahan P, Chen JL. Mini-Open Achilles Repair With a Flat Braided Suture in a Low-Profile Configuration. Arthrosc Tech 2021; 10:e451-e455. [PMID: 33680778 PMCID: PMC7917089 DOI: 10.1016/j.eats.2020.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/18/2020] [Indexed: 02/03/2023] Open
Abstract
Achilles repair has evolved over the past 30 years, from large open procedures with high complication rates to shorter, less-invasive procedures with better outcomes. Percutaneous repair has comparable failure rates with open repairs, fewer complications, and faster recovery. However, percutaneous Achilles repairs risk sural nerve injury. A mini-open repair fuses the gap between percutaneous and open procedures, and this approach has the potential to mitigate nerve injury while maintaining the increased efficiency in procedure time and patient recovery. The purpose of this Technical Note and accompanying video is to outline the repair of the Achilles tendon using a mini open repair using a low-profile flat braided suture.
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Affiliation(s)
- Stewart A. Bryant
- Address correspondence to Stewart A. Bryant, M.D., Advanced Orthopaedics and Sports Medicine, 450 Sutter St., Ste 400, San Francisco, CA 94108.
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Carpenter D, Dederer K, Weinhold P, Tennant JN. Clinical Outcomes and Cadaveric Biomechanical Analysis of Endoscopic Percutaneous Achilles Tendon Rupture Repair With Absorbable Suture. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420965967. [PMID: 35097413 PMCID: PMC8564947 DOI: 10.1177/2473011420965967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Percutaneous repair of acute Achilles tendon rupture (ATR) continues to gain in popularity. The primary aim of the study was to review the outcomes of a patient cohort undergoing a novel technique of endoscopic percutaneous Achilles tendon repair with absorbable suture. A secondary purpose of this study was to evaluate the basic biomechanical properties of the technique. Methods: A cohort of 30 patients who underwent percutaneous ATR repair was retrospectively analyzed with Achilles Tendon Rupture Scores (ATRS), complications, and additional outcome measures. For a biomechanical analysis portion of the study, 12 cadaveric specimens were paired and randomized to either novel percutaneous repair or open Kessler repair with absorbable suture. These specimens were subjected to 2 phases of cyclical testing (100 cycles 10-43 N followed by 200 cycles 10-86 N) and ultimate strength testing. Results: In the clinical portion of the study we report excellent patient reported outcomes (mean ATRS 94.1), high level of return to sport, and high patient satisfaction. One partial re-rupture was reported but with no major wound or neurologic complications. In the biomechanical portion of the study we found no significant difference in tendon gapping between percutaneous and open repairs in phase 1 of testing. In phase 2, increased gapping occurred between percutaneous (17.8 mm [range 10.7-24.1, SD 6.4]) and open repairs (10.8 mm [range 7.6-14.9, SD 2.7, P = .037]). The ultimate load at failure was not statistically different between the 2 repairs. Conclusions: A percutaneous ATR repair technique using endoscopic assistance and absorbable suture demonstrated low complications and good outcomes in a cohort of patients, with high satisfaction, and excellent functional outcomes including high rates of return to sport. Cadaveric biomechanical testing demonstrated excellent survival during testing and minimal increase in gapping compared with open repair technique, representing sufficient strength to withstand forces seen in early rehabilitation. A percutaneous Achilles tendon repair technique with absorbable suture may minimize risks associated with operative repair while still maintaining the benefit of operative repair. Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
| | | | - Paul Weinhold
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Joshua N. Tennant
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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TÜZÜN HY, ERŞEN Ö, TÜRKKAN S, ARSENİSHVİLİ A, KÜRKLÜ M. Perkütan Aşil tendon rüptürü tamiri: güvenli ve güvenilir mi? EGE TIP DERGISI 2020. [DOI: 10.19161/etd.790413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Holzgrefe RE, McCarthy TP, Wilson JM, Bariteau JT, Labib S. Association of Strength Following Achilles Tendon Repair With Return to Same Level of Play in High-Level Athletes. Foot Ankle Int 2020; 41:1041-1048. [PMID: 32660267 DOI: 10.1177/1071100720936276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rupture of the Achilles tendon is a common injury and the ability to return to the same level of sporting activity after treatment is an important outcome for patients. The objective of the current study was to examine the relationship between ankle strength and the ability to return to previous level of play following operative repair of an Achilles tendon rupture. METHODS Patients aged 18 to 50 years at a minimum 1 year postoperation from surgical repair of an Achilles tendon returned for a study visit. Patients reported both preinjury and current activity level using the 10-point Tegner Activity Level Scale. Isokinetic strength testing was performed and the Isokinetic Strength Score (ISS) was calculated. Logistic regression analysis was used to determine the relationship between ISS and return to play by Tegner level. A total of 36 patients (mean 35 years old, 72% male) completed the study protocol at a mean 1.8 years postoperatively. RESULTS Logistic regression revealed no association between ISS and return to play in the complete cohort. Subgroup analysis revealed that for 20 high-level athletes (preinjury Tegner ≥ 7), for every 16-point increase in ISS, the odds ratio (OR) for return to same level of play was 8.3 (P = .055) and the OR for return to within 1 Tegner level of play was 6.3 (P = .043). There was no association between ISS and return to previous activity in the 16 patients with lower preinjury levels of activity. CONCLUSION Improved ankle strength was associated with return to previous level of activity in patients participating in high-level athletic activity, suggesting that these patients were more dependent on recovery of ankle strength in the postoperative time period in order to return to their previous high level of play. In contrast, regaining strength may be less important for returning to normal activities for less active patients. LEVEL OF EVIDENCE Level III, comparative series.
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Affiliation(s)
| | - Timothy P McCarthy
- USAF, Landstuhl Regional Medical Center, Landstuhl, Rhineland-Palatinate, Germany
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Jason T Bariteau
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Sameh Labib
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
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Post-operative MRI and US appearance of the Achilles tendons. J Ultrasound 2020; 23:387-395. [PMID: 32488649 DOI: 10.1007/s40477-020-00479-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 12/17/2022] Open
Abstract
The Achilles tendon is one of the most commonly ruptured tendons in the human body. Minimally invasive and open surgical repairs are commonly undertaken to manage acute Achilles ruptures. This article describes the postoperative imaging findings and their evolution after surgery. Ultrasound and magnetic resonance imaging provide crucial information regarding the morphology, structure, vascularization and mobility of the Achilles tendon on the surrounding planes. Morphologically, a repaired tendon is physiologically larger and wider than an intact one, with a loss of its fibrillary structure; the presence of surgical material in the context of the tendon is normal after the rupture has been repaired. After surgery, the tendon is more vascularized in power-Doppler imaging. Elastography and diffusion tensor Imaging are innovative tools which allow for the visualization of microstructural abnormalities not apprehensible using conventional imaging techniques. A treated Achilles tendon is unlikely to regain a normal imaging appearance, and the health care professional must distinguish between postoperative findings and actual pathological features. In this context, clinical examination still reigns supreme.
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Fell D, Enocson A, Lapidus LJ. Surgical repair of acute Achilles tendon ruptures: a follow-up of 639 consecutive cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:895-899. [DOI: 10.1007/s00590-020-02650-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/03/2020] [Indexed: 11/30/2022]
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Joannas G, Arrondo G, Eslava S, Casola L, Drago J, Barousse R, Niño Gomez D, Amlang M, Rammelt S. Percutaneous Achilles tendon repair with the Dresden instrument. Clinical and MRI evaluation of 90 patients. Foot Ankle Surg 2020; 26:209-217. [PMID: 30853390 DOI: 10.1016/j.fas.2019.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/31/2018] [Accepted: 02/15/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aims at evaluating a substantial number of patients treated with a percutaneous, paratenon preserving technique for Achilles tendon repair using three different incisions with clinical follow-up and magnetic resonance imaging (MRI). METHODS Ninety patients with percutaneous Achilles tendon repair using the Dresden technique for acute rupture were evaluated. Fifteen patients were treated using a central approach, 15 patients using a posterolateral approach and the original posteromedial approach was used in 60 patients. All patients were followed clinically and with MRI after 1 and 6 months post-operatively. RESULTS Using the standard posteromedial approach no complications were seen. With the central approach 4 (27%) wound healing problems were observed and with the posterolateral approach 2 (13%) sural nerve lesions occurred. One patient (1.1%) had a rerupture. MRI revealed an increased diameter at the rupture site and distal to it as well as an increasingly homogeneous signal over time. CONCLUSIONS Percutaneous Achilles tendon repair with the Dresden technique yields excellent clinical results and a low complication rate. Modification of the original incision is discouraged.
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Affiliation(s)
| | | | | | | | - Juan Drago
- Instituto Dupuytren, Buenos Aires, Argentina
| | | | | | - Michael Amlang
- University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Stefan Rammelt
- University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany.
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Wagner P, Wagner E, López M, Etchevers G, Valencia O, Guzmán-Venegas R. Proximal and Distal Failure Site Analysis in Percutaneous Achilles Tendon Rupture Repair. Foot Ankle Int 2019; 40:1424-1429. [PMID: 31462088 DOI: 10.1177/1071100719867937] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Different techniques have been described for percutaneous Achilles tendon rupture repair, but no biomechanical evaluation has been performed separately for proximal and distal suturing techniques. The purpose of this study was to biomechanically analyze proximal versus distal percutaneous Achilles suture configurations during cyclic loading and load to failure. METHODS A simulated, midsubstance rupture was created 6 cm proximal to the calcaneal insertion in fresh-frozen cadaveric Achilles tendons. Fifteen proximal specimens were divided into 3 groups: (A1) triple locking technique, (A2) Bunnell-type technique, and (A3) double Bunnell-type technique. Twelve distal specimens were divided into 2 groups: (B1) triple nonlocking technique and (B2) oblique technique. Repairs were subjected to cyclic testing and load to failure. Load to failure, cause of failure, and tendon elongation were evaluated. RESULTS None of the proximal specimens and 7/12 of the distal ones failed in cyclic testing. The proximal fixation groups demonstrated significantly more strength than the distal groups (P = .001), achieving up to 710 N of failure load in Group A3. Groups B1and B2 failed on average at 380 N with no difference between them (P > .05). The majority of all repairs failed in the suture-tendon interface. Distal groups had more elongation during cyclic testing (13.7 mm) than proximal groups (9.4 mm) (P = .02). CONCLUSION The distal fixation site in this Achilles tendon repair was significantly weaker than the proximal fixation site. A proximal modified suture configuration increased resistance to cyclic loading and load to failure significantly. CLINICAL RELEVANCE A modification can be suggested to improve strength of the Achilles repair.
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Affiliation(s)
- Pablo Wagner
- Foot and Ankle Surgeon, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile.,Hospital Militar de Santiago, Universidad de los Andes, Santiago, Chile
| | - Emilio Wagner
- Foot and Ankle Surgeon, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Mario López
- Foot and Ankle Surgeon, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Gastón Etchevers
- Foot and Ankle Surgeon, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Oscar Valencia
- Laboratorio LIBFE, Escuela de kinesiología, Facultad de Medicina, Universidad de los Andes, Santiago, Chile
| | - Rodrigo Guzmán-Venegas
- Laboratorio LIBFE, Escuela de kinesiología, Facultad de Medicina, Universidad de los Andes, Santiago, Chile
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Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG. Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119884071. [PMID: 31803789 PMCID: PMC6878623 DOI: 10.1177/2325967119884071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines. PURPOSE To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture. RESULTS A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53). CONCLUSION Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.
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Affiliation(s)
- Jennifer A. Zellers
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marianne Christensen
- Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Inge Lunding Kjær
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
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Abstract
The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Adrian J Yenchak
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - David P Trofa
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - J Turner Vosseller
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
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Lu J, Liang X, Ma Q. Early Functional Rehabilitation for Acute Achilles Tendon Ruptures: An Update Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg 2019; 58:938-945. [PMID: 31474405 DOI: 10.1053/j.jfas.2018.12.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Indexed: 02/03/2023]
Abstract
The aim of this study was to investigate the role of early functional rehabilitation in acute Achilles tendon ruptures. Eligible studies were identified from PubMed, Embase, and the Cochrane Library using the following search keywords: "Achilles tendon rupture" and "rehabilitation" or "function" or "functional" or "mobilization" and "randomized" or "random" or "blind" or "control" or "compare" or "comparative." A heterogeneity test based on I2 statistic and Cochran's Q test was conducted. The pooled risk ratio and weighted mean difference with 95% confidence interval was calculated for each outcome using the random-effect (p < .05 or I2 > 50% for significant heterogeneity) or fixed-effect (p > .05 or I2 < 50% for nonsignificant heterogeneity) model. A subgroup analysis was also performed. Fourteen randomized controlled trials were identified. Pooled data demonstrated no difference in the complication rates, time taken to return to sports, total number of patients returning to work or sports, and satisfaction rate between the early functional rehabilitation and conventional cast immobilization groups. Early functional rehabilitation significantly decreased the time taken to return to work (weighted mean difference -1.56; 95% confidence interval -3.09 to 0.04; p = .04]. Early functional rehabilitation for acute Achilles tendon ruptures appeared to be related to a shorter time taken to return to work; however, it did not affect the other variables between the groups.
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Affiliation(s)
- Jun Lu
- Surgeon, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China
| | - Xiaojun Liang
- Professor, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China
| | - Qiang Ma
- Surgeon, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China.
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31
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Baumfeld D, Baumfeld T, Spiezia F, Nery C, Zambelli R, Maffulli N. Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears. Foot Ankle Surg 2019; 25:503-506. [PMID: 30321959 DOI: 10.1016/j.fas.2018.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/09/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rupture of the Achilles tendon (AT) is frequent in young recreational athletes. Conservative management, open surgery and percutaneous/minimally invasive approaches are all advocated, and conflicting data are available. This study compared functional and anthropometric outcomes of patients who underwent open or percutaneous repair. METHODS A retrospective comparative study, in which 38 patients underwent open and percutaneous techniques to manage AT ruptures. For functional assessment, the calf circumference of both injured and uninjured legs was evaluated. Isokinetic testing included total plantar flexion work, peak plantar flexion torque, total dorsiflexion work peak and dorsiflexion torque. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) were evaluated at a final minimum follow-up of 12months. RESULTS No major complications were observed. The average time to return to sport was 9months. AOFAS and ATRS values did not differ statistically between groups. Isokinetic variables and circumference were similar in the operated and non-operated limb in both groups, and did not differ either when comparing open and percutaneous repair. CONCLUSIONS Open and percutaneous repair of a torn Achilles tendon produced similar functional outcomes.
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Affiliation(s)
| | | | - Filippo Spiezia
- Department of Orthopaedic and Trauma Surgery, Ospedale San Carlo, Presidio Ospedaliero di Villa D'Agri, Viale S. Pio da Pietrelcina, 85050 Villa d'Agri, Marsicovetere, PZ, Italy.
| | - Caio Nery
- Federal University of São Paulo (UNIFESP), Brazil.
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32
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Stavenuiter XJR, Lubberts B, Prince RM, Johnson AH, DiGiovanni CW, Guss D. Postoperative Complications Following Repair of Acute Achilles Tendon Rupture. Foot Ankle Int 2019; 40:679-686. [PMID: 30808187 DOI: 10.1177/1071100719831371] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Controversy remains regarding which patients with acute Achilles tendon rupture would best be treated nonoperatively and which might benefit from operative repair. The primary aim of this study was to characterize the overall incidence of-and specific risk factors associated with-postoperative complications that follow operative repair. We also evaluated the specific differences between complications after the use of an open or minimally invasive surgical (MIS) approach. METHODS Retrospective chart review identified 615 adult patients who underwent operative repair for an acute Achilles tendon rupture between January 1, 2001, and May 1, 2016, at 3 level I trauma centers. Minimum follow-up was 3 months. Patient demographics, comorbidities, injury mechanism, procedural details, and surgeon subspecialty were collected. Assessed complications included wound healing issues, rerupture, hematoma, nerve injury, deep vein thrombosis, and pulmonary embolism. RESULTS Seventy-two patients (11.7%) developed a postoperative complication. Risk factors included advancing patient age (odds ratio [OR], 1.04, P = .007), active tobacco use (OR, 3.20, P = .007), and specific subspecialty training (OR, 2.04, P = .046). No difference in overall complication rate was found between the open and MIS approaches (11.6% vs 13.2%, P = .658). A subgroup analysis among orthopedic subspecialties demonstrated that patients treated by trauma surgeons had increased rates of wound complication ( P = .043) and rerupture ( P = .025) compared with those treated by other subspecialties. Patients treated by trauma surgeons were also more likely to be younger or have a body mass index (BMI) > 30, although neither factor was found to be independently predictive for postoperative complications. CONCLUSION Approximately 1 in 9 patients undergoing operative repair of an acute Achilles tendon rupture developed a postoperative complication. Advancing age and active tobacco use were independent risk factors for developing such complications. Differences in subspecialty training also appear to impact complication rates, but the potential reason for this discrepancy remains unclear. As controversy remains regarding which patients who sustain acute Achilles tendon rupture should be treated nonoperatively and which would benefit most from surgical repair, a better understanding of postoperative complication rates and associated risk factors may enhance the decision-making processes in treating these injuries. It is not clear whether MIS techniques are superior to traditional open repair in terms of postoperative complications. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- X J Ruben Stavenuiter
- 1 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, Boston MA, USA
| | - Bart Lubberts
- 1 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, Boston MA, USA
| | - Robert M Prince
- 1 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, Boston MA, USA
| | - A Holly Johnson
- 2 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, Newton-Wellesley Hospital, MA, USA
| | - Christopher W DiGiovanni
- 2 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, Newton-Wellesley Hospital, MA, USA
| | - Daniel Guss
- 2 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, Newton-Wellesley Hospital, MA, USA
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de Cesar Netto C, Bernasconi A, Roberts L, Saito GH, Hamilton WG, O'Malley MJ. Open Re-rupture of the Achilles Tendon Following Minimally Invasive Repair: A Case Report. J Foot Ankle Surg 2019; 57:1272-1277. [PMID: 30115453 DOI: 10.1053/j.jfas.2018.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Indexed: 02/03/2023]
Abstract
In this report, we describe a rare complication of an open re-rupture of the Achilles tendon following a minimally invasive Achilles tendon repair on a healthy 29-year-old active male. The reinjury happened 19 weeks following the primary surgical repair of a spontaneous rupture, performed by minimally invasive technique with the help of a jig using partially absorbable sutures and four locking stitches. The wound of the open re-rupture was transverse, in a perpendicular orientation relative to the longitudinal approach used in the index procedure. Increased scar tissue formation, the absence of an adequate layer of paratenon overlying the primary tendon repair, and foreign-body reaction to the suture may have been involved in the occurrence of this unusual complication in the surgical treatment of Achilles tendon rupture.
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Affiliation(s)
| | | | - Lauren Roberts
- Clinical Fellow, Hospital for Special Surgery, New York, NY
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Abstract
Objectives The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2.
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Affiliation(s)
- X Yang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - H Meng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Q Quan
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - J Peng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - S Lu
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - A Wang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
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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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Anathallee MY, Liu B, Budgen A, Stanley J. Is Achillon repair safe and reliable in delayed presentation Achilles tendon rupture? A five-year follow-up. Foot Ankle Surg 2018; 24:296-299. [PMID: 29409244 DOI: 10.1016/j.fas.2017.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 02/16/2017] [Accepted: 02/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND To assess the outcome of delayed repair of ruptured Achilles tendon using the Achillon mini-open technique. METHODS A review of all patients who underwent delayed repair (>10 days post injury) of ruptured Achilles tendon with mini invasive technique was compared to acute repairs carried out at the same unit. Leppilahti Score and Achilles Tendon Total Rupture Score (ATRS) were utilised. Complication rates including re-rupture were also reviewed. RESULTS 14 patients were identified as having delayed repair (11-31 days). The mean follow-up period was 71 months (range: 58-92). There were no statistically significant difference in the Leppilahti Score and ATRS compared to patients treated acutely (<10 days post injury) in the same time period. 79% of patients with delayed repair reported good to excellent, comparable to 80% of patients having undergone acute repair. CONCLUSIONS For those patients who would benefit from surgical repair, a mini-open technique using the Achillon suture-passing device remains a safe and reliable option for delayed presentation of 11-31 days.
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Affiliation(s)
- M Yasser Anathallee
- Trauma & Orthopaedics Department, York District Hospital, Wigginton Road, York, YO31 8HE, UK.
| | - Ben Liu
- Trauma & Orthopaedics Department, York District Hospital, Wigginton Road, York, YO31 8HE, UK
| | - Adam Budgen
- Trauma & Orthopaedics Department, York District Hospital, Wigginton Road, York, YO31 8HE, UK
| | - James Stanley
- Trauma & Orthopaedics Department, York District Hospital, Wigginton Road, York, YO31 8HE, UK
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Deng S, Sun Z, Zhang C, Chen G, Li J. Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg 2018; 56:1236-1243. [PMID: 29079238 DOI: 10.1053/j.jfas.2017.05.036] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Indexed: 02/03/2023]
Abstract
Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains controversial. The aim of the present study was to compare the clinical outcomes of surgical treatment versus conservative management for acute Achilles tendon rupture. Eight randomized controlled studies involving 762 patients were included in the meta-analysis. In general, re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%). Pooled results showed that the total re-rupture rate was significantly lower in surgical group than that in the nonsurgical group (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p = .001). No significant differences were found between the 2 treatment groups in the incidence of deep venous thrombosis, the number who returned to sport, ankle range of motion (dorsiflexion, plantarflexion), Achilles tendon total rupture score, or physical activity scale. Surgical treatment can effectively reduce the re-rupture rate and might be a better choice for the treatment of acute Achilles tendon rupture. Multicenter, double-blind randomized controlled trials with stratification and long-term follow-up are needed to obtain a higher level of evidence and to guide clinical practice, especially in the comparison and selection of different treatments.
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Affiliation(s)
- Senlin Deng
- Orthopedist, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhengyu Sun
- Orthopedist, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chenghao Zhang
- Orthopedist, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Chen
- Orthopedist, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Orthopedist, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China; Professor, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China.
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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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Rungprai C, Phisitkul P. Outcomes and Complications Following Endoscopically Assisted Percutaneous Achilles Tendon Repair. Arthroscopy 2018; 34:1262-1269. [PMID: 29273251 DOI: 10.1016/j.arthro.2017.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To review functional and clinical outcomes as well as complications in patients who underwent endoscopically assisted percutaneous Achilles tendon repair using 4-strand core suture configuration via a 6-portal technique. METHODS A retrospective chart review with prospectively collected data was performed in 23 consecutive patients who underwent endoscopically assisted percutaneous Achilles tendon repair between 2008 and 2015. The minimum follow-up to be included in the study was 24 months. The primary outcome was Foot and Ankle Ability Measure (FAAM), Activities of Daily Living (ADL) and Sports subscales; Short Form-36 (SF-36), physical and mental component summaries (PCS and MCS); and visual analog scale (VAS). The secondary outcomes included tourniquet time, recovery time, and complications. RESULTS Twenty-three patients (18 males and 5 females, all unilateral) with the mean age of 36.7 years were included and 6 patients were repaired using an open technique because they did not meet the inclusion criteria owing to presenting late in the clinic (injury more than 2-3 weeks). The average time to final follow-up was 54.1 months. The average tourniquet time was 41.3 minutes. There was significant improvement of VAS (7.9/10 to 0.1/10), SF-36 (PCS, 32.5-44.7, and MCS, 47.9-51.4), and FAAM (ADL, 26.1.0-83.0, and Sports, 0-61.7). The average time to return to activities of daily living, work, and sports were 8.0 weeks, 8.8 weeks, and 5.7 months, respectively. The postoperative morbidity included superficial wound infection at the portal (1 patient with underlying type 2 diabetes, 4.3%) and there was no rerupture, deep vein thrombosis, sural nerve injury, and painful scar in this study. CONCLUSIONS Endoscopically assisted percutaneous Achilles tendon repair has significant improvement in terms of functional outcomes as measured with the FAAM, SF-36, and VAS. This technique is safe and feasible with minimal postoperative pain and morbidities, early return to activities, and satisfactory functional outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Chamnanni Rungprai
- Department of Orthopaedic and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Iowa, U.S.A.; Department of Orthopaedic Surgery, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Phinit Phisitkul
- Department of Orthopaedic Surgery, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.
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Liechti DJ, Moatshe G, Backus JD, Marchetti DC, Clanton TO. A Percutaneous Knotless Technique for Acute Achilles Tendon Ruptures. Arthrosc Tech 2018; 7:e171-e178. [PMID: 29552483 PMCID: PMC5851437 DOI: 10.1016/j.eats.2017.08.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/11/2017] [Indexed: 02/03/2023] Open
Abstract
Achilles tendon ruptures are a common tendon injury, usually occurring in middle-aged men during recreational sporting activities. Both nonoperative and operative management are employed to treat these injuries. Several operative treatments are described in the literature, including percutaneous Achilles repair, mini-open repair, and open repair. Open Achilles repair is associated with higher rates of impaired wound healing and infection, whereas minimally invasive techniques have been reported to have an increased risk of iatrogenic sural nerve injury. More recently, low complication rates, improved cosmetic appearance, reduced operating times, and improved clinical outcomes have been reported for the percutaneous Achilles repair technique. In this Technical Note, we present our preferred technique using the Percutaneous Achilles Repair System (Arthrex, Naples, FL), which has been reported to have minimal wound and nerve complications, and early return to activity.
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Affiliation(s)
| | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Jonathon D Backus
- Cornerstone Orthopaedics and Sports Medicine, Louisville, Colorado, U.S.A
| | | | - Thomas O Clanton
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A
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Ling SKK, Slocum A, Lui TH. 5-year results of the 1.5cm incision Achilles tendon repair. Foot (Edinb) 2017; 33:35-38. [PMID: 29126040 DOI: 10.1016/j.foot.2017.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 06/02/2017] [Accepted: 06/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND To study a hypothesis that the cost-effective 1.5cm medial incision Achilles tendon repair technique will provide good functional outcomes which are maintained for over 5 years. METHOD Prospective study of 12 consecutive cases with a minimal 5-year follow-up were recruited from April 2008 to November 2010. Cases whom were mentally incompetent or those which required concomitant procedures were excluded. Outcomes measures included the numeric pain rating scale, motor power strength, range of motion, functional scoring using the AOFAS hindfoot score and patient's self-assessment using the Foot and Ankle Outcome Score (FAOS). RESULT No re-ruptures or sural nerve injured were identified after a minimal 5-year follow-up. Pain was minimal at 0.5/10, calf power was 5/5 and ankle range was good (plantarflexion: 38°/dorsiflexion: 21°). The AOFAS hindfoot score was 97.4 and all 5 sub-categories of the Foot and Ankle Outcome Score (FAOS) were good. CONCLUSION The 1.5cm medial incision repair of the Achilles tendon is an economically sound surgical technique, with minimal complications, which gives good medium length functional outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Samuel K K Ling
- Dept. of Orthopadics & Traumatology, North District Hospital, Hong Kong Special Administrative Region.
| | - Amanda Slocum
- Dept. of Orthopadics & Traumatology, North District Hospital, Hong Kong Special Administrative Region.
| | - T H Lui
- Dept. of Orthopadics & Traumatology, North District Hospital, Hong Kong Special Administrative Region.
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Dekker RG, Qin C, Lawton C, Muriuki MG, Havey RM, Alshouli M, Patwardhan AG, Kadakia A. A Biomechanical Comparison of Limited Open Versus Krackow Repair for Achilles Tendon Rupture. FOOT & ANKLE ORTHOPAEDICS 2017. [DOI: 10.1177/2473011417715431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Soft tissue complications after Achilles tendon repair has led to increased interest in less invasive techniques. Various limited open techniques have gained popularity as an alternative to open operative repair. The purpose of this study was to biomechanically compare an open Krackow and limited open repair for Achilles tendon rupture. We hypothesized that there would be no statistical difference in load to failure, work to failure, and initial linear stiffness. Methods: A simulated Achilles tendon rupture was created 4 cm proximal to its insertion in 18 fresh-frozen cadaveric below-knee lower limbs. Specimens were randomized to open or limited open PARS Achilles Jig System repair. Repairs were loaded to failure at a rate of 25.4 mm/s to reflect loading during normal ankle range of motion. Load to failure, work to failure, and initial linear stiffness were compared between the 2 repair types. Results: The average load to failure (353.8 ± 88.8 N vs 313.3 ± 99.9 N; P = .38) and work to failure (6.4 ± 2.3 J vs 6.3 ± 3.5 J; P = .904) were not statistically different for Krackow and PARS repair, respectively. Mean initial linear stiffness of the Krackow repair (17.8 ± 5.4 N/mm) was significantly greater than PARS repair (11.8 ± 2.5 N/mm) ( P = .011). Conclusion: No significant difference in repair strength was seen, but higher initial linear stiffness for Krackow repair suggests superior resistance to gap formation, which may occur during postoperative rehabilitation. With equal repair strength, but less soft tissue devitalization, the PARS may be a favorable option for patients with risk factors for soft tissue complications.
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Affiliation(s)
- Robert G. Dekker
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Charles Qin
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Cort Lawton
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Muturi G. Muriuki
- Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Robert M. Havey
- Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL, USA
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maywood, IL, USA
| | - Mohammed Alshouli
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Avinash G. Patwardhan
- Musculoskeletal Biomechanics Laboratory, Edward Hines Jr. VA Hospital, Hines, IL, USA
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maywood, IL, USA
| | - Anish Kadakia
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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Kim U, Choi YS, Jang GC, Choi YR. Early rehabilitation after open repair for patients with a rupture of the Achilles tendon. Injury 2017; 48:1710-1713. [PMID: 28465006 DOI: 10.1016/j.injury.2017.04.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/16/2017] [Accepted: 04/24/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE As outdoor activities participation increase, Achilles tendon rupture incidence also tends to increase. There are a number of treatment and rehabilitation options for a ruptured Achilles tendon. However, the optimal rehabilitation protocols are still under debate. The purpose of this study is to determine whether early rehabilitation is more effective than conventional rehabilitation. METHODS Medical records of 56 patients who had been treated with open repair after a ruptured Achilles tendon were retrospectively reviewed. 24 patients were treated postoperatively with below knee cast immobilization for four weeks, and they started tolerable weight-bearing rehabilitation at four weeks' follow-up. The remaining 32 patients were managed postoperatively with short leg splint immobilization for two weeks and started the tolerable weight-bearing at two weeks' follow-up. We evaluated the patients several times to identify when the single heel raise was possible and measured the American Orthopedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) as a functional outcome. RESULTS The single heel raise test was positive in all patients at the last assessment. But there were no statistically significant differences between the groups (p=0.137). The patients in the Cast group took significantly more time to return to work than did the patients in the Splint group (p=0.032). And AOFAS scores and ATRS were slightly higher in the Splint group than in the Cast group. There were statistically significant differences (p=0.042, p=0.028) between the two groups. CONCLUSION The early rehabilitation did not lead to greater endurance, but it showed better results in the return to work and the Achilles functional score. Early rehabilitation after open repair for patients with a ruptured Achilles tendon is helpful for functional recovery. Type of study / Level of evidence: Therapeutic, Level III.
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Affiliation(s)
- Uk Kim
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, School of Medicine, CHA University, Seong-nam, Republic of Korea
| | - Yun Seong Choi
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, School of Medicine, CHA University, Seong-nam, Republic of Korea
| | - Gyu Chol Jang
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, School of Medicine, CHA University, Seong-nam, Republic of Korea
| | - Young Rak Choi
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, School of Medicine, CHA University, Seong-nam, Republic of Korea.
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Ho G, Tantigate D, Kirschenbaum J, Greisberg JK, Vosseller JT. Increasing age in Achilles rupture patients over time. Injury 2017; 48:1701-1709. [PMID: 28457569 DOI: 10.1016/j.injury.2017.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE Level III; Retrospective cohort study.
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Affiliation(s)
- Gavin Ho
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Direk Tantigate
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Josh Kirschenbaum
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Justin K Greisberg
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - J Turner Vosseller
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States.
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Rensing N, Waterman BR, Frank RM, Heida KA, Orr JD. Low Risk for Local and Systemic Complications After Primary Repair of 1626 Achilles Tendon Ruptures. Foot Ankle Spec 2017; 10:216-226. [PMID: 27837039 DOI: 10.1177/1938640016676340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Historically, Achilles tendon repairs and other surgeries about the hindfoot have demonstrated a significantly higher rate of wound healing complications and surgical site morbidity. The purpose of this study was to evaluate the comprehensive complication profile and risk factors for adverse short-term, clinical outcomes after primary repair of Achilles tendon ruptures. METHODS Between the years 2005 and 2014, all cases of primary Achilles tendon repair (Current Procedural Terminology code 27650) entered into the National Surgical Quality Improvement Project (NSQIP) database were extracted for analysis. Primary outcomes of interest were rates of total complication, reoperation, and rerupture within 30 days of index surgery. Independent risk factors associated with these selected endpoints were assessed with chi-square and logistic regression analysis and odds ratios with 95% confidence intervals were used to express relative risk. RESULTS Of 1626 patients with an average age of 44 years (SD 13.3), the average ASA classification was 1.69 and hypertension (20.7%), morbid obesity (8.3%), and diabetes (4.9%) were among the most common medical comorbidities. A total of 28 (1.7%) patients sustained perioperative complications, including 1.3% with local complications (0.7% superficial wound infection, 0.4% wound disruption) and no cases of peripheral nerve injury or early repair failure. Systemic complications occurred in 0.4%, most commonly with deep venous thrombosis or nonfatal thromboembolism. Preoperative albumin was independently associated with an increased risk of local wound complications (odds ratio [OR] 28.67; 95% CI 1.42-579.40; P = .029). Chronic obstructive pulmonary disease (OR 22.33, 95% CI 2.49-199.81; P = .006) and bleeding disorder (OR 14.83, 95% CI 1.70-129.50; P = .015) were more likely to result in a systemic complication, and preoperative creatinine correlated with an increased risk of any complication (OR 6.11, 95% CI 1.15-32.34; P = .033). In total there were 5 (0.3%) readmissions with 2 (0.1%) unplanned reoperations attributed to local wound complications. CONCLUSION Among a broad-based demographic of the United States, the rate of local wound complications was exceedingly low in the short-term perioperative period, although this risk may be significantly magnified with subtle decreases in albumin levels. Preoperative risk stratifications should carefully scrutinize for subtle abnormalities in nutritional parameters and renal function prior to undergoing Achilles surgery. LEVELS OF EVIDENCE Therapeutic, Level II: Prospective, comparative trial.
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Affiliation(s)
- Nicholas Rensing
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Brian R Waterman
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Rachel M Frank
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Kenneth A Heida
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Justin D Orr
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
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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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Clinical failure after Dresden repair of mid-substance Achilles tendon rupture: human cadaveric testing. Knee Surg Sports Traumatol Arthrosc 2017; 25:1849-1856. [PMID: 27256278 DOI: 10.1007/s00167-016-4182-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to describe the angle of clinical failure during cyclical mobilization exercises in the Achilles tendon of human cadaveric specimens that were repaired using the Dresden technique and FiberWire® No. 2. The secondary aim was to identify the secure limit of mobilization, the type of failure, and the type of apposition. METHODS The lower limbs of eight males (mean age: 60.3 ± 6.3 years) were repaired with the Dresden technique following complete, percutaneous mid-substance Achilles tendon rupture. A basal tension of 10 N at 30° of plantarflexion was placed on each specimen. The angle of the ankle during clinical failure (tendon ends separation >5 mm) was then tested via cyclical exercises (i.e. 100 cycles between 30° and 15° of plantarflexion; 100 cycles between 15° of plantarflexion and 0°; 100 cycles between 0° and 15° of dorsiflexion; and 100 cycles between 15° of dorsiflexion and full dorsiflexion). Clinical failure was determined using the Laplacian edge detection filter, and the angle of clinical failure was obtained using a rotatory potentiometer aligned in relation to the intermalleolar axis of each foot specimen. The type of failure (knot, tendon, or suture) and apposition (termino-terminal or non-termino-terminal) were determined. Descriptive statistics were used to obtain the mean; standard deviation; 95 % confidence interval; 1st, 25th, 50th, 75th, and 100th percentiles; and the standard error of the mean for angle data. Proportions were used to describe the type of failure and apposition. RESULTS The main results were a mean angle of clinical failure equal to 12.5° of plantarflexion, a limit of mobilization equal to 14.0° of plantarflexion, tendon failure type, and non-termino-terminal apposition in all specimens. CONCLUSIONS While the mean angle of clinical failure in human cadaveric models was 12.5° of plantarflexion, after 14.0° of plantarflexion, the percutaneous Dresden technique was found insecure for cyclical mobilization exercises, with a 5 % range of error. These findings are clinically relevant as they provide mechanical limits for diminishing the risk of Achilles lengthening during immediate rehabilitation.
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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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Cottom JM, Baker JS, Richardson PE, Maker JM. Evaluation of a New Knotless Suture Anchor Repair in Acute Achilles Tendon Ruptures: A Biomechanical Comparison of Three Techniques. J Foot Ankle Surg 2017; 56:423-427. [PMID: 28476383 DOI: 10.1053/j.jfas.2016.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Indexed: 02/03/2023]
Abstract
Acute ruptures of the Achilles tendon are a common injury, and debate has continued in published studies on how best to treat these injuries. Specifically, controversy exists regarding the surgical approaches for Achilles tendon repair when one considers percutaneous versus open repair. The present study investigated the biomechanical strength of 3 different techniques for Achilles tendon repair in a cadaveric model. A total of 36 specimens were divided into 3 groups, each of which received a different construct. The first group received a traditional Krackow suture repair, the second group was repaired using a jig-assisted percutaneous suture, and the third group received a repair using a jig-assisted percutaneous repair modified with suture anchors placed into the calcaneus. The specimens were tested with cyclical loading and to ultimate failure. Cyclical loading showed a trend toward a stronger repair with the use of suture anchors after 10 cycles (p = .295), 500 cycles (p = .120), and 1000 cycles (p = .040). The ultimate load to failure was greatest in the group repaired with the modified knotless technique using the suture anchors (p = .098). The results of the present study show a clear trend toward a stronger construct in Achilles repair using a knotless suture anchor technique, which might translate to a faster return to activity and be more resistant to an early and aggressive rehabilitation protocol. Further clinical studies are warranted to evaluate this technique in a patient population.
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Affiliation(s)
- James M Cottom
- Fellowship Director, Attending Physician, Florida Orthopedic Foot & Ankle Center, Sarasota, FL.
| | - Joseph S Baker
- Fellow, Foot and Ankle Surgical Fellowship, Florida Orthopedic Foot & Ankle Center, Sarasota, FL
| | - Phillip E Richardson
- Fellow, Foot and Ankle Surgical Fellowship, Florida Orthopedic Foot & Ankle Center, Sarasota, FL
| | - Jared M Maker
- Fellow, Foot and Ankle Surgical Fellowship, Florida Orthopedic Foot & Ankle Center, Sarasota, FL
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DeVries JG, Scharer BM, Summerhays BJ. Acute Achilles Rupture Percutaneous Repair: Approach, Materials, Techniques. Clin Podiatr Med Surg 2017; 34:251-262. [PMID: 28257678 DOI: 10.1016/j.cpm.2016.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Closed traumatic Achilles tendon rupture is a common injury, especially in the aging athlete. Traditionally open repair has been recognized to offer a lower rerupture rate compared with nonoperative methods but with a higher complication rate. Percutaneous repair has been described to offer the benefits of open repair while avoiding the complications. The sural nerve is potentially susceptible to injury, and specialized instrumentation has been developed to avoid this event. This article discusses several techniques of minimally invasive Achilles tendon repair. Many authors have evaluated these techniques and the results are discussed here.
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Affiliation(s)
- Jason George DeVries
- Orthopedics & Sports Medicine, BayCare Clinic, 2020 Riverside Drive, Green Bay, WI 54301, USA.
| | - Brandon M Scharer
- Orthopedics & Sports Medicine, BayCare Clinic, 2020 Riverside Drive, Green Bay, WI 54301, USA
| | - Benjamin J Summerhays
- Orthoaedic Surgery, University of Missouri Health, 1100 Virginia Avenue, Columbia, MO 65212, USA
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