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Feng SM, Maffulli N, Oliva F, Saxena A, Hao YF, Hua YH, Xu HL, Tao X, Xu W, Migliorini F, Ma C. Surgical management of chronic Achilles tendon rupture: evidence-based guidelines. J Orthop Surg Res 2024; 19:132. [PMID: 38341569 PMCID: PMC10858558 DOI: 10.1186/s13018-024-04559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/11/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes. METHODS A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines. RESULTS Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol. CONCLUSION Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.
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Affiliation(s)
- Shi-Ming Feng
- Orthopaedic Department, Sports Medicine Department, Xuzhou Central Hospital, No. 199, the Jiefang South Road, Xuzhou, 221009, Jiangsu, China.
| | - Nicola Maffulli
- Department of Medicine and Psychology, University "La Sapienza", Rome, Italy
- Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Stoke-On-Trent, Staffordshire, ST4 7QB, England
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
| | - Francesco Oliva
- Department of Sports Traumatology, Universita' Telematica San Raffaele, Rome, Italy
| | - Amol Saxena
- Department of Sports Medicine, Sutter-PAMF, Palo Alto, CA, USA
| | - Yue-Feng Hao
- Orthopedics and Sports Medicine Center, Suzhou Municipal Hospital, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Ying-Hui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Hai-Lin Xu
- Department of Trauma and Orthopedic, People's Hospital, Peking University, Beijing, People's Republic of China
| | - Xu Tao
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Wei Xu
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
| | - Chao Ma
- Orthopaedic Department, Sports Medicine Department, Xuzhou Central Hospital, No. 199, the Jiefang South Road, Xuzhou, 221009, Jiangsu, China
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Ma Y, Meng X, Su Y, Yan Z, Shao Q, Chen Y. Evaluation of a Modified Spoon-Shaped Medial Incision in the Surgical Repair of a Chronic Achilles Tendon Rupture. J Foot Ankle Surg 2021; 60:729-732. [PMID: 33773920 DOI: 10.1053/j.jfas.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 02/03/2023]
Abstract
This study aims to investigate the clinical significance of preventing incision skin necrosis and the improved function offered in patients with a chronic Achilles tendon rupture treated surgically with a modified spoon-shaped medial incision. From January 2013 to January 2017, 50 patients (N = 50) who were admitted to our department with a clinically and radiologically confirmed chronic Achilles tendon rupture met inclusion criteria and were divided retrospectively into two groups. In group A (n = 26), a modified spoon-shaped medial incision in the surgical repair of Achilles tendon rupture was performed. In group B (n = 24), a traditional posterior medial incision was used. All skin healing was observed. Functional evaluation was performed using American Orthopedic Ankle & Foot Society scale(AOFAS) hindfoot score and Achilles tendon total rupture score(ATRS). Return-to-work time and major complications were also measured. The patients were followed for 12 to 48 months. All incisions exhibited primary healing in group A, while four incisions healed delay for skin necrosis which includes superficial, deeper necrosis, and skin defection caused by the necrosis in group B. Both groups had similar results regarding return-to-work time. There were no infections in either group. There was no rerupture of the Achilles tendon in either group. Patients in group A had better AOFAS hindfoot score (p = .020) and ATRS (p = .010), and the difference was significant (p ≤ .05).Using the modified spoon-shaped medial incision in the surgical repair of a chronic Achilles tendon rupture seems to be a safe and effective method that may reduce risk of incision skin necrosis and offers better function in patients with a chronic Achilles tendon rupture.
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Affiliation(s)
- Yanming Ma
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Xiangjun Meng
- Professor, Department of Ophthalmology, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Yun Su
- Professor, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China.
| | - Zuofa Yan
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Quansheng Shao
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Yiqing Chen
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
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Jain M, Tripathy SK, Behera S, Das SS, Rana R, Gantaguru A. Functional outcome of gastrocnemius advancement flap augmented with short flexor hallucis longus tendon transfer in chronic Achilles tear. Foot (Edinb) 2020; 45:101704. [PMID: 33038661 DOI: 10.1016/j.foot.2020.101704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are various techniques of Achilles tendon (TA) repair and reconstruction in chronic Achilles tear. However, there is no clear consensus on the relevance of one method over the other. The short flexor hallucis longus tendon (FHL) transfer has recently gained popularity because of its same phasic action, ease of harvesting and tensile strength. METHODOLOGY Fifteen chronic Achilles tear (>6 weeks) were treated with tendon repair using gastrocnemius advancement flap augmented with FHL transfer. The patients were followed-up at 1.5, 3, 6, 12 and 24 months. The clinical outcome at latest follow-up was evaluated using the American Orthopedic Foot and Ankle Score (AOFAS) and the Achilles Tendon Rupture Score (ATRS). RESULTS The mean age was 43.5 ± 12.4 years and the median time from injury to surgery was 17.13 ± 9.64 weeks. The mean gap between the retracted ends of the ruptured tendon was 5.67 ± 1.63 cm (range 4-10 cm). The mean follow-up was 19.07 ± 3.15 months (range, 13-24 months). The mean AOFAS and ATRS improved from 72.07 ± 8.29 (62-83) to 98.4 ± 2.03 (94-100) and 61.73 ± 8.16 (52-70) to 98 ± 1.85 (94-100) respectively (paired t-test, p-value 0.0001). All patients resumed their pre-injury daily activities, and there was no donor site morbidity. Two patients had sterile serous discharge, and one patient had a staphylococcus infection. These patients responded to debridement with prolonged antibiotic therapy. There were no nerve injuries or re-rupture. CONCLUSION The functional outcome of chronic Achilles tear treated with gastrocnemius advancement flap augmented with short FHL transfer is rewarding.
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Affiliation(s)
- Mantu Jain
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sudarsan Behera
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sudhanshu Sekhar Das
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
| | - Rajesh Rana
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
| | - Amrit Gantaguru
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
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Gendera HAM, Lambers-Heerspink FO, Bruls VE, Drees MMW. Extensive Achilles tendon ossification: Repair using a fascia lata graft. Foot (Edinb) 2020; 43:101663. [PMID: 32120284 DOI: 10.1016/j.foot.2020.101663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 01/17/2020] [Accepted: 01/26/2020] [Indexed: 02/06/2023]
Abstract
Ossification of the Achilles tendon is a relatively common finding. However, a large ossification covering more than two third of the tendon is rarely seen. A 70 year old patient with a 12 cm long Achilles tendon ossification is discussed. The ossification was surgically removed and the tendon was subsequently reconstructed using a fascia lata autograft. Postoperatively the ankle was immobilised for 3 months. One year postoperatively the patient was completely recovered with the ability to stand on his toes, and minimal loss in range of motion. LEVEL OF CLINICAL EVIDENCE: 4.
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Affiliation(s)
- H A M Gendera
- Department of Orthopaedic Surgery and Traumatology, Venlo, Viecuri Medisch Centrum, The Netherlands.
| | - F O Lambers-Heerspink
- Department of Orthopaedic Surgery and Traumatology, Venlo, Viecuri Medisch Centrum, The Netherlands
| | - V E Bruls
- Department of Orthopaedic Surgery and Traumatology, Venlo, Viecuri Medisch Centrum, The Netherlands
| | - M M W Drees
- Department of Orthopaedic Surgery and Traumatology, Venlo, Viecuri Medisch Centrum, The Netherlands
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Periasamy M, Venkatramani H, Shanmuganathan RS. Management of Chronic Achilles Tendon Injuries-Review of Current Protocols and Surgical Options. Indian J Plast Surg 2019; 52:109-116. [PMID: 31456619 PMCID: PMC6664832 DOI: 10.1055/s-0039-1687923] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Chronic Achilles tendon injury is a challenging problem. A review of the different options available and their technical considerations is required. Reconstruction of the Achilles tendon depends on numerous factors such as the gap between the debrided tendon ends, the presence of a distal stump, and the and presence of scar tissue. Various protocols have been described for reconstruction. Methods of reconstruction vary from direct repair, bridging of the tendon gap with tendon grafts or tendon transfers. We review and enumerate the different protocols enumerated for the reconstruction of chronic Achilles tendon lesions in the literature and look at the authors preferred methods of reconstruction
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Affiliation(s)
- Madhu Periasamy
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
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Achilles tendon reconstruction with a half-width Achilles graft and wrap-around fascial flap. Arch Plast Surg 2019; 46:267-271. [PMID: 30974517 PMCID: PMC6536867 DOI: 10.5999/aps.2018.00066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 08/30/2018] [Indexed: 12/27/2022] Open
Abstract
A 70-year-old man complained imbalance while walking, inability to perform ankle flexion, and could not stand on tip-toe 3 months after injury. The ankle looked swollen with loss of Achilles contour and obvious gait disturbance. Magnetic resonance imaging shows a 5-cm Achilles tendon gap. Subsequently, surgery was performed to solve the neglected Achilles tendon rupture. Patient was put under general anesthesia with a regional block. Using a non-tourniquet technique, a reconstructive procedure was performed using a half-width autologous Achilles tendon graft, which was attached to the calcaneal prominence with wire in a double strand Bunnell fashion. As for the proximal stump, double core Bunnell/modified Kessler suturing was carried out to suture the graft to Achilles stump. To increase the vascularization, an ipsilateral gastrocnemius fascial flap with a distally based-pedicle was harvested to wrap around the tendon graft. At a 6-month follow-up, the patient was able to stand on tip-toe and had also regained a normal gait.
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Buda R, Castagnini F, Pagliazzi G, Giannini S. Treatment Algorithm for Chronic Achilles Tendon Lesions Review of the Literature and Proposal of a New Classification. J Am Podiatr Med Assoc 2017; 107:144-149. [PMID: 28394684 DOI: 10.7547/15-099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. Surgical treatment is usually required. The current English literature (PubMed) about CATLs was revised, and particular emphasis was given to articles depicting CATL classification. The available treatment algorithms are based on defect size. We propose the inclusion of other parameters, such as tendon degeneration, etiology, and time from injury to surgery. Partial lesions affecting less than (I stage) or more than (II stage) half of the tendon should be treated conservatively for healthy tendons, within 12 weeks of injury. In II stage complex cases, an end-to-end anastomosis is required. Complete lesions inferior to 2 cm should be addressed by an end-to-end anastomosis, with a tendon transfer in the case of tendon degeneration. Lesions measuring 2 to 5 cm require a turndown flap and a V-Y tendinous flap in the case of a good-quality tendon; degenerated tendons may require a tendon transfer. Lesions larger than 5 cm should be treated using two tendon transfers and V-Y tendinous flaps. A proper algorithm should be introduced to calibrate the surgical procedures. In addition to tendon defect size, tendon degeneration, etiology of the lesion, and time from injury to surgery are crucial factors that should be considered in the surgical planning.
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Benny A, Balg F, Svotelis A, Vézina F. Reconstruction of Overlengthening After Gastrocnemius Recession With an Achilles Tendon Allograft: Case Report. Foot Ankle Int 2016; 37:1249-1254. [PMID: 27344054 DOI: 10.1177/1071100716655354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Alexandre Benny
- Division of Orthopedic Surgery, Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Frédéric Balg
- Division of Orthopedic Surgery, Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Amy Svotelis
- Division of Orthopedic Surgery, Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - François Vézina
- Division of Orthopedic Surgery, Department of Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada
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Abstract
Abstract
Disorders of the Achilles tendon, the largest tendon in the human body, are common and occur in both active and sedentary persons. A thorough history and physical examination allow primary care physicians to make an accurate diagnosis and to initiate appropriate management. Mismanaged or neglected injuries markedly decrease a patient’s quality of life. A growing body of related literature is the basis for current therapeutic regimens, which use a multimodal conservative approach, including osteopathic manipulative treatment. Although primary care physicians can manage most cases of Achilles tendon disorders, specialty care may be needed in certain instances. Procedural intervention should consider any comorbid conditions in addition to patients’ lifestyle to help guide decision making. When appropriately managed, Achilles tendon disorders generally carry a favorable prognosis.
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Moshiri A, Oryan A, Meimandi-Parizi A. Synthesis, development, characterization and effectiveness of bovine pure platelet gel-collagen-polydioxanone bioactive graft on tendon healing. J Cell Mol Med 2015; 19:1308-32. [PMID: 25702535 PMCID: PMC4459846 DOI: 10.1111/jcmm.12511] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 11/06/2014] [Indexed: 01/21/2023] Open
Abstract
Bovine platelet gel (BPG) is an accessible and cost-effective source of growth factors which may have a value in tendon regenerative medicine. We produced a collagen implant (CI) as a tendon proper, covered it with polydioxanone (PDS) sheath to simulate paratenon and finally embedded the BPG as an active source of growth factor within the bioimplant to test whether BPG would be able to accelerate and enhance tendon regeneration and repair. After in vitro characterization of the bioactive grafts, the grafts were implanted in rabbit large tendon defect model. Untreated tendons and tendons treated with either CI or CI-PDS were served as controls for the CI-PDS-BPG. The animals were investigated clinically, ultrasonographically and haematologically for 120 days. After euthanasia, dry matter content, water uptake and delivery characteristics and also gross morphological, histopathological and scanning electron microscopic features of the healing tendons were assessed. In vitro, the activated platelets in the scaffold, released their growth factors significantly more than the controls. BPG also increased cell viability, and enhanced cellular differentiation, maturation and proliferation inside the CI-PDS compared with the controls. In vivo, the BPG modulated inflammation, increased quality and rate of fibroplasia and produced a remodelled tendon that had significantly higher collagen content and superior collagen fibril and fibre differentiation than controls. Treatment also significantly improved tendon water uptake and delivery characteristics, animals' serum PDGF level, CI-PDS biocompatibility and biodegradability and reduced peritendinous adhesions, muscle fibrosis and atrophy. BPG was effective on tendon healing and CI-PDS-BPG may be a valuable bioscaffold in tendon reconstructive surgery.
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Affiliation(s)
- Ali Moshiri
- Division of Surgery and Radiology, Department of Clinical Science, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Ahmad Oryan
- Department of Pathology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Abdolhamid Meimandi-Parizi
- Division of Surgery and Radiology, Department of Clinical Science, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
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