A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture

Functional Outcome in Percutaneous Achilles Tendon Repair

Background

Rupture of the Achilles tendon is a considerable cause of morbidity with reduced function following injury. Randomized studies have so far failed to show a difference in outcome between operative and nonoperative management of Achilles tendon rupture, provided that no re-rupture occurs. Percutaneous Achilles repair has been suggested to result in superior patient satisfaction compared with open repair in patients with an acute Achilles tendon rupture.

Aim and Objectives

To assess and evaluate the functional outcome after percutaneous repair in patients of the acute and closed Achilles tendon ruptures.

Materials and Methods

It was a prospective study conducted on patients diagnosed as having rupture of the Achilles tendon. A total of 25 patients with mean age of 44.4 (range 19-65) years were taken, who underwent percutaneous Achilles tendon repair.

Results

The number of patients who reported excellent or good scores (ATRS > 80) at 3, 6 and 12 months were 0%, 16% and 100%, respectively. The mean AOFAS hind foot score at 3-, 6- and 12-month follow-ups was 77.9 ± 4.3, 92.04 ± 2.4 and 96.16.32 ± 1.1, respectively. The number of patients who reported excellent or good scores (AOFAS > 74) at 3, 6 and 12 months were 76%, 100% and 100%, respectively. Most of the patients in our study showed no complications, and only 2 (8%) of patients had the features of sural nerve injury which was resolved in the subsequent follow-ups.

Conclusion

Percutaneous repair of the Achilles tendon is an effective procedure which gives excellent functional outcome with very few complications. The percutaneous technique gives an additional advantage of less operative time, no wound complications, less damage to the soft tissues, and improved cosmesis as compared to the open repair.

Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses

PURPOSE

To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR.

METHODS

Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance.

RESULTS

There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation.

CONCLUSION

This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR.

LEVEL OF EVIDENCE

IV.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrates improved time-zero biomechanical and promising short to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint over-constraint, nerve paresthesia, and infection.

Application of Preoperative Ultrasonography in the Percutaneous Minimally Invasive Repair of Acute Closed Achilles Tendon Rupture

Percutaneous minimally invasive surgery involving Achilles tendon (AT) repair has the advantages of a low rerupture rate and fewer postoperative complications. However, due to the inability to operate under direct vision, the injury of the small saphenous vein (SSV) and sural nerve (SN) remains largely a high risk involving many challenges. We propose to introduce the preoperative application and advantages of ultrasonography in percutaneous minimally invasive surgery for acute AT rupture. Our results indicated that ultrasonography could locate the position of the SN more accurately and reduce the risk of iatrogenic nerve injury. Compared with the traditional surface markers, the preoperative localization and marking of AT, SSV, and SN in ultrasonography significantly reduced the risk of intraoperative accidental injury to blood vessels and nerves, which could reduce postoperative complications and promote early rehabilitation of patients. We ultimately exploit the properties of ultrasonography in percutaneous minimally invasive surgery to treat Achilles tendon rupture.

Jigless Knotless Internal Brace Versus Other Minimal Invasive Achilles Tendon Repair Techniques in Biomechanical Testing Simulating the Progressive Rehabilitation Protocol

The jigless knotless internal brace surgery (JKIB), an alternative method for minimal invasive surgery (MIS) repair of acute Achilles tendon rupture, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as previous clinical research demonstrates. However, no comparative study on the biomechanical performance between JKIB and other MIS techniques has been reported until now. In this study, 50 fresh porcine Achilles tendons were used to compare the JKIB with open surgery (two-stranded Krachow suture) with other MIS techniques, including Percutaneus Achilles Repair System (PARS), Speedbridge (SB), and Achillon Achilles Tendon Suture System (ACH), using a biomechanical testing with cyclic loading at 1 Hz. This test was used to simulate a progressive rehabilitation protocol where 20 to 100 N was applied in the first 250 cycles, followed by 20 to 190 N in the second 250 cycles, and then 20 to 369 N in the third 250 cycles. The cyclic displacement after 10, 100 and 250 cycles were recorded. The survived cycles were defined as a sudden drop in measured load. In survived cycles, the JKIB group (552.3 ± 72.8) had significantly higher cycles than the open, PARS, and ACH groups (204.3 ± 33.3, 395.9 ± 96.0, and 397.1 ± 80.9, respectively, p < .01) as analyzed by post hoc analysis, but no significant difference as compared with the SB group (641.6 ± 48.7). In cyclic displacement after 250 cyclic loadings, the JKIB group (11.29 ± 1.29) showed no significant difference as compared with PARS, SB, and ACH groups (12.21 ± 1.18, 9.80 ± 0.80, and 11.57 ± 1.10 mm, respectively) and significant less displacement than the open group (14.50 ± 1.85, p < .01). These findings suggest that JKIB could be an option for acute Achilles tendon repair in the MIS fashion due to no larger cyclic elongation compared with other MIS techniques.

Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair

Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.

Ultrasound evaluation of a new surface reference line to describe sural nerve location and safe zones to consider in posterior leg approaches

PURPOSE

Several authors have described methods to predict the sural nerve pathway with non-proportional numerical distances, but none have proposed a person-proportional, reproducible method with anatomical references. The aim of this research is to describe ultrasonographically the distance and crossing zone between a surface reference line and the position of the sural nerve.

METHODS

Descriptive cross-sectional study, performed between January and April 2022 in patients requiring foot surgery who met inclusion criteria. The sural nerve course in the posterior leg was located and marked using ultrasound. Landmarks were drawn with a straight line from the medial femoral condyle to the tip of the fibula. Four equal zones were established in the leg by subdividing the distal half of the line. This way, areas based on simple anatomical proportions for each patient were studied. The distance between the marking and the ultrasound nerve position was measured in these 4 zones, creating intersection points and safety areas. Location and distances from the sural nerve to the proposed landmarks were assessed.

RESULTS

One-hundred and four lower limbs, 52 left and 52 right, assessed in 52 patients were included. The shortest median distance of the nerve passage was 2.9 mm from Point 2. The sural nerve intersection was 60/104 (57.7%) in Zone B, 21/104 (20.1%) in Zone C and 19/104 (18.3%) in Zone A. Safety zones were established. Average 80.5% of coincidence in sural nerve localization was found in the distal half of the leg, in relation to the surface reference line when comparing both legs of each patient.

CONCLUSIONS

This study proposes a simple, reproducible, non-invasive and, for the first time, person-proportional method, that describes the distance and location of the main areas of intersection of the sural nerve with points and zones (risk and safe zones) determined by a line guided by superficial anatomical landmarks. Its application when surgeons plan and perform posterior leg approaches will help to avoid iatrogenic nerve injuries.

LEVEL OF EVIDENCE

IV.

[Less invasive turn-down flap tendinoplasty in chronic Achilles tendon rupture]

OBJECTIVE

Bridging the defect in chronic ruptures of the Achilles tendon via a turn-down flap of the aponeurosis sparing the skin of the rupture zone.

INDICATIONS

Chronic Achilles tendon rupture with a defect distance ≤ 6 cm.

CONTRAINDICATIONS

Extended Achilles tendon defect interval ≥ 7 cm, chronic wounds or infections near the surgical approach, higher degrees of arterial or venous malperfusion, complex regional pain syndrome.

SURGICAL TECHNIQUE

Dorsomedial surgical approach proximal to the rupture zone, splitting of the crural fascia, loading of the distal Achilles tendon stump with a nonresorbable augmentation suture using the Dresden instrument, preparation of the turn-down flap of the aponeurosis securing the turning point with a catching suture. Transfer of the turn-down tendon flap under the skin bridge and suture to the distal tendon stump tying the augmentation suture under adequate pretension simultaneously closing the gap in the aponeurosis. Alternative technique: free advancement of the autologous tendon graft.

POSTOPERATIVE MANAGEMENT

Anterior splint in 20° of plantar flexion, consecutive mobilization and rehabilitation similar to the percutaneous technique in acute Achilles tendon rupture with the Dresden instrument. Lower leg orthosis with 20° of plantarflexion for 8 weeks, then stepwise reduction of the heel height. Physiotherapy beginning from the 2nd postoperative week, active full-range of ankle motion from 6 weeks after surgery.

RESULTS

In general, worse results than in percutaneous reconstruction of acute Achilles tendon injuries. Despite this, high degrees of patient satisfaction with a low rate of postsurgical complications and good functional outcome with admittedly poor data availability. Relevant increase of plantar flexion strength depending on the amount of degeneration of the triceps surae muscle.

Outcomes of Percutaneous Achilles Repair Compared With Endoscopic Flexor Hallucis Longus Tendon Transfer to Treat Achilles Tendon Ruptures

BACKGROUND

Both percutaneous and endoscopically assisted methods are reported to produce good results in the surgical management of acute Achilles tendon ruptures. The aim of this retrospective study was to compare between a percutaneous method and a recently described isolated endoscopically assisted flexor hallucis longus (FHL) transfer method as surgical means of management in patients with acute Achilles tendon ruptures.

METHODS

One hundred seventeen patients were included in the current study and divided into 2 groups: 59 patients who underwent percutaneous Achilles repair (PAR Group) and 58 patients who underwent isolated endoscopic FHL transfer (FHL Group) were compared. Patients were clinically evaluated using American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score (ATRS), and Achilles tendon resting angle (ATRA) measures. In addition, ankle plantarflexion power, FHL dynamometry, Tegner activity levels, and return to previous levels of activity were also documented for all patients.

RESULTS

Nine months after surgery, patients in the FHL transfer group were more likely to be able to return to normal activities (91% vs 73%, P < .01). Thirty months after surgical treatment, we found no difference in ATRS, AOFAS, ATRA, ankle plantarflexion strength, or Tegner activity scores between study groups. Overall complications were reported in 6 patients in the FHL group (10.3%) and in 8 patients in the PAR group (13.6%). No major neurovascular or skin complications were encountered.

CONCLUSION

The current study demonstrated satisfactory and comparable results and complications when comparing isolated endoscopic FHL tendon transfer or percutaneous Achilles tendon repairs in the surgical management of acute Achilles tendon ruptures.

LEVEL OF EVIDENCE

Level III, retrospective controlled trial.

Achilles: Failed Acute Repair

Acute Achilles tendon ruptures are commonly managed with surgical repair. This particular surgery is prone to rerupture, wound complications, deep vein thrombosis, and sural nerve injuries. In this chapter the authors discuss complications, how to avoid them, and ultimately how to manage complications with your patients.

An Anatomic Study of the Sural Nerve Using 3-Tesla MRI: A Comparison to Cadaveric Data With Surgical Applications

BACKGROUND

The sural nerve (SN) is a sensory cutaneous nerve that is at risk of iatrogenic injury during surgery at the lateral ankle. Prior anatomic studies of the SN are limited primarily to cadaveric studies with small sample sizes. Our study analyzed a large cohort of magnetic resonance images (MRIs) of the ankle to obtain a more generalizable, in vivo sample of distal SN course.

METHODS

A total of 204 3-tesla MRI studies of the ankle were analyzed. Three reviewers measured the distance from the SN to various landmarks including the distal tip of the lateral malleolus (DTLM) and the lateral border of the Achilles tendon (LBA).

RESULTS

Mean vertical distance from SN to DTLM was 2.2 cm (range, 0.9-3.6 cm). Mean horizontal distance from SN to DTLM and to LBA at the level of DTLM was 1.7 cm (range, 0.8-3.0 cm) and 1.9 cm (range, 1.0-2.9 cm), respectively. Mean horizontal distance from SN to LBA at the level of superior Achilles tendon insertion onto the calcaneus (SAI) was 2.6 cm (range, 1.4-3.7 cm), and mean horizontal distance from SN to LBA at 5 cm above SAI was 0.9 cm (range, 0.4-1.8 cm).

CONCLUSION

The variation in SN course observed in our study allowed us to propose "safe zones" for several surgical approaches including the extensile lateral approach to the calcaneus (ELAC), the sinus tarsi approach (STA), the direct lateral approach to the lateral malleolus (DLA), and the posterolateral approach to the ankle (PLA), which we hope will minimize iatrogenic injury to the SN.

LEVEL OF EVIDENCE

Level IV, case series.

Comparison Study of Mini-Incision Versus Original Open Technique of the Half-Mini-Bunnell Achilles Tendon Repair

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.

Minimally Invasive Repair of Subacute Achilles Tendon Ruptures: A Report of 2 Cases

Level IV: Case report.

Jigless knotless internal brace versus other open Achilles tendon repairs using a progressive rehabilitation protocol: a biomechanical study

BACKGROUND

The jigless knotless internal brace surgery (JKIB), a modified minimal invasive surgery (MIS) for acute Achilles tendon injury, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as demonstrated in previous clinical research. However, to date, biomechanical testing has not yet been validated.

MATERIALS AND METHODS

Sixty fresh porcine Achilles tendons were used to compare the JKIB with other open surgery techniques, the four-stranded Krackow suture (4sK) and the triple-bundle suture (TBS) in biomechanical testing with cyclic loading set at 1 Hz. This approach simulated a progressive rehabilitation protocol where 20-100 N was applied in the first 1000 cycles, followed by 20-190 N in the second 1000 cycles, and then 20-369 N in the third 1000 cycles. The cycles leading to repair gaps of 2 mm, 5 mm, and 10 mm were recorded. The survival cycles were defined as repair gap of 10 mm.

RESULTS

With respect to survival cycles, a significant difference was found among the three groups, in which the TBS was the most robust, followed by the JKIB and the 4sK, where the mean survived cycles were 2639.3 +/- 263.55, 2073.6 +/- 319.92, and 1425.25 +/- 268.96, respectively. Significant differences were verified via a post hoc analysis with the Mann-Whitney U test after the Bonferroni correction (p < 0.017).

CONCLUSIONS

The TBS was the strongest suture structure in acute Achilles tendon repair. However, the JKIB could be an option in acute Achilles tendon repair with the MIS technique due to it being more robust than the 4sK, which has been typically favored for use in open repair.

What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

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.

Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair

BACKGROUND

There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques.

METHODS

A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution's registry. Demographics and complications were recorded.

RESULTS

PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection).

CONCLUSION

Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Influence of Early Weightearing, Controlled Motion, and Timing of Orthosis Removal on the Nonoperative Management of Achilles Tendon Rupture: A Systematic Review

This is a systematic review of the non-operative treatment for Achilles tendon rupture aimed at assessing the effect of early weightbearing, controlled motion and orthosis removal on 5 outcome measures. The literature was searched for relevant RCTs and prospective cohort studies. The primary outcome measure was the re-rupture rate. The secondary outcome measures were the rates for DVT, duration before return to work (RTW), return to sports (RTS) and the mean Achilles Tendon Rupture Score (ATRS). Eighteen publications reporting a total of 1068 patients were reviewed. The pooled rates were: re-rupture: 7.3%, DVT: 5.5%, RTW: 10.3 weeks, RTS: 47.7% and ATRS: 78.7. Early compared to late weightbearing was associated with significantly lower rates of DVT, RTW and ATRS but no difference in the rates of re-rupture and RTS. Early controlled motion compared to no motion was associated with significantly lower rates of re-rupture, RTW and ATRS but no difference in the rates of DVT and RTS. Early compared to late orthosis removal was associated with significantly higher rates of re-rupture and ATRS as well as a lower rate of RTW but no difference in the rates of DVT and RTS. The findings relating to re-rupture, DVT, RTW and RTS support the adoption of early weightbearing and controlled motion in the non-operative treatment for Achilles tendon rupture. Early removal of orthosis is not advisable due to an increased risk of re-rupture. The ATRS results were considered inconclusive probably due to inconsistencies in the reporting or heterogeneity in the study population.

ACFAS Clinical Consensus Statement: Acute Achilles Tendon Pathology

Injuries to the Achilles tendon are a challenge to the foot and ankle surgeon. In recent years, research has led to a relative change in the way that many surgeons view acute Achilles tendon rupture. In an effort to fully evaluate these trends, as well as to evaluate all aspects of care for acute Achilles tendon rupture, the American College of Foot and Ankle Surgeons convened a panel of experts to create a clinical consensus statement to address selected aspects of care of the acute Achilles tendon injury.

How Do Sports Medicine and Foot and Ankle Specialists Treat Acute Achilles Tendon Ruptures?

Background. The purpose of this study is to evaluate the treatment considerations and surgical techniques utilized by fellowship-trained orthopaedic sports medicine and foot and ankle specialists in the management of Achilles tendon ruptures. Methods. A blinded electronic survey was distributed to 2062 fellowship-trained sports medicine and 1319 fellowship-trained foot and ankle orthopaedic surgeons. The total number of acute Achilles tendon ruptures managed per year, patient-specific factors associated with surgical decision making and surgical techniques were evaluated. Results. Of the 3381 surveys distributed, 524 responses were included for analysis. Only 9% of respondents manage more than 20 acute Achilles tendon ruptures per year with the majority (75%) managing less than 10 per year. Operative management is the treatment of choice for 76% of total respondents with only 8% managing acute ruptures nonoperatively. Activity level and patient age were the single most important factors for 60.8% and 29.3% of surgeons, respectively, with regard to operative versus nonoperative decision making. Socioeconomic status and workers compensation were the least important patient factors. Conclusion. Surgical repair in the young and active patient is the preferred treatment for the majority of fellowship-trained subspecialists who most commonly encounter this pathology.Levels of Evidence: Therapeutic, Level V: Consensus of Expert Analysis.

Acute Achilles Tendon Ruptures

There is an ever-evolving debate about the best treatment option for Achilles tendon ruptures. There was a relative consensus that operative treatment yielded the best outcomes. Much of this is based on results in athletic populations. Conservative treatment was considered only for the elderly and those with very inactive lifestyles. There has been an evolution, however, with more surgeons utilizing an aggressive functional rehabilitation with conservative management. Surgical intervention still is the treatment of choice for elite-level athletes. The treatment of choice for patient populations other than elite athletes remains an individual choice between patient and physician.

Mini-Open Achilles Repair With a Flat Braided Suture in a Low-Profile Configuration

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.

Achillon versus modified minimally invasive repair treatment in acute Achilles tendon rupture

PURPOSE

To date, the best treatment of acute Achilles tendon rupture (AATR) is still inconclusive. Achillon seems to be a promising approach with satisfactory function and low complication rate. We hypothesize a modified minimally invasive repair (MMIR), which provides direct visualization of proximal tendon stump without specialized equipment that could provide comparable results. This trial is aimed to evaluate the functional and surgical outcomes of MMIR comparing with Achillon.

METHODS

From February 2013 to February 2017, 114 patients with AATR were enrolled in this trial, underwent an alternative operation (Achillon or MMIR), and accelerated rehabilitation protocol. Forty-four patients took the Achillon and the other 70 patients took the MMIR at their subjective choice. One hundred eleven full follow-up data were obtained including Achilles tendon total rupture score (ATRS), time back to work, rerupture rate, overall complication rate, and operation time.

RESULTS

There was no significant difference between groups in demographic characters. There was no statistical difference between both groups regarding to time return to work and ATRS at 3rd, 6th, 12th, and 24th month, respectively. Five reruptures and two Achilles tendons tethering to skins were found in the Achillon group, and two reruptures and one sural nerve injury in the MMIR group. No wound infection and dehiscence occurred. Overall complication rate in the Achillon group is higher (16.3% vs. 4.4%, p = 0.044). The operation time of Achillon is less than MMIR (34.84 vs. 39.71, p < 0.001).

CONCLUSION

Both techniques combining with accelerated rehabilitation showed to be reliable and effective. MMIR is safer and more economical, and Achillon is faster.

Higher Rate of Postoperative Complications in Delayed Achilles Tendon Repair Compared to Early Achilles Tendon Repair: A Meta-Analysis

BACKGROUND

Some authors found that delayed repair of Achilles tendon ruptures achieved similar functional outcomes when compared with acute repair of Achilles tendon ruptures. The purpose of our study was to compare functional outcomes and complication rates of acute repair to delayed repair after Achilles tendon ruptures.

METHODS

PubMed, Embase (Ovid) and the Cochrane Library were searched.

RESULTS

For Achilles tendon rupture score (ATRS), the overall result revealed that there was no significant difference in ATRS between acute repair groups and delayed repair groups (P = 0.59). For Tegner scores, Halasi scores and Achilles tendon resting angle (ATRA), there was no significant difference between the two groups (P = 0.28, P = 0.47 and P = 0.68). There was no significant difference in the subjective assessment between acute repair groups and delayed repair groups (P = 0.84). However, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.01). Subgroup analyses showed that the mean time from injury to surgery of delayed repair groups affect the pooled result substantially. For mean time less than 28d, there was no difference in the incidence of complications between acute repair groups and delayed repair groups (P = 0.09). However, for mean time more than 28d, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.05).

CONCLUSION

Our study showed delayed repair could obtain similar functional outcomes and subjective assessment when compared with acute repair. However, the rate of complications after delayed repair was higher than that of early repair. Further high-quality randomized controlled trials (RCT) are needed to evaluate the difference.

Modified Bunnell suture repair versus bundle-to-bundle suture repair for acute Achilles tendon rupture: a prospective comparative study of patients aged <45 years

BACKGROUND

This study aimed to compare the operative outcome of percutaneous repair (modified Bunnell suture technique) versus open repair (bundle-to-bundle suture technique) of acute Achilles tendon rupture.

METHODS

Seventy-two consecutive patients who underwent surgical treatment of Achilles tendon rupture were evaluated in this prospective study. Thirty-six patients were treated using the bundle-to-bundle suture technique (group A), and 36 patients were treated using the modified Bunnell suture technique (group B). All patients underwent functional examination comprising measurement of the calf muscle circumference and performance of the single-leg heel-rise test. The length and diameter of the Achilles tendon were compared between the injured and uninjured sides on magnetic resonance imaging. The number of single-leg heel rises (height > 5 cm) performed within 15 s was compared between the injured and uninjured sides. The ankle range of motion was also recorded. The Achilles tendon total rupture score (ATRS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, and visual analog scale (VAS) pain score were used to evaluate the clinical outcome at 12 months postoperatively.

RESULTS

A total of 61 patients were followed up. The mean follow-up duration did not significantly differ between group A (23.73 ± 2.81 months) and group B (22.61 ± 3.96 months). However, there were significant differences between groups in the heel-rise test (group A, 1.74 ± 0.96; group B, 2.37 ± 1.42) and length of the Achilles tendon (group A, 11.98 ± 1.64 cm; group B, 11.11 ± 1.74 cm). The calf circumference of the injured side was significantly larger in group A than in group B (p = 0.043). The cross-sectional diameter of the Achilles tendon was significantly smaller in group A than group B. At final follow-up, there were no significant differences between the two groups in the ATRS, AOFAS score, or VAS score. One patient in group A had delayed wound healing, which resolved in 40 days.

CONCLUSIONS

Patients with acute Achilles tendon rupture treated with open repair (bundle-to-bundle suture technique) achieved a better clinical outcome regarding the heel-rise test and calf circumference compared with those treated with percutaneous repair (modified Bunnell suture technique).

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000035229 , 8/4/2020, Retrospectively registered.

Intraoperative ultrasonography assistance for minimally invasive repair of the acute Achilles tendon rupture

Background

Minimally invasive repair is a better option for Achilles tendon rupture with low re-rupture and wound-related complications than conservative treatment or traditional open repair. The major problem is sural nerve injury. The purpose of this study was to evaluate the effect and advantage of the intraoperative ultrasonography assistance for minimally invasive repair of the acute Achilles tendon rupture.

Methods

A retrospective study was performed on 36 cases of acute Achilles tendon rupture treated with minimally invasive repair assisted with intraoperative ultrasonography from January 2015 to December 2017. The relationship of the sural nerve and small saphenous vein was confirmed on the preoperative MRI. The course of the small saphenous vein and the sural nerve was identified and marked by intraoperative ultrasonography. The ruptured Achilles tendon was repaired with minimally invasive Bunnell suture on the medial side of the small saphenous vein (SSV).

Results

All patients were followed up for at least 12 months. No sural nerve injury or other complications was found intraoperatively and postoperatively. All the patients returned to work and light sporting activities at a mean of 12.78 ± 1.40 weeks and 17.28 ± 2.34 weeks, respectively. The Mean American Orthopaedic Foot & Ankle Society (AOFAS) scores improved from 59.17 ± 5.31 preoperatively to 98.92 ± 1.63 at the time of 12 months follow-up. There was a statistically significant difference (P < 0.001). No patient complained of a negative effect on their life.

Conclusions

The minimally invasive repair assisted with intraoperative ultrasonography can yield good clinical outcomes, less surgical time, and less complications, especially sural nerve injury. It is an efficient, reliable, and safe method for acute Achilles tendon (AT) rupture.

Minimally Invasive Achilles Repair Techniques

Achilles tendon rupture is an increasingly common problem with an aging population participating in high-level physical activities. Appropriate treatment has been debated for decades, but good outcomes have been reported after conservative and surgical management. The development of minimally invasive surgical techniques for Achilles repair has reduced the incidence of complications and maintained the high level of function reported after open surgery. The Achilles Midsubstance SpeedBridge repair is a newer minimally invasive technique that has demonstrated promising results and is the authors' preferred treatment of Achilles tendon rupture in athletes and active patients.

Repair of Combined Insertional and Midsubstance Achilles Tendon Ruptures

Complex combined tears of the insertion and midsubstance of the Achilles tendon are rare injuries that are challenging to diagnose and treat. The author describes a novel technique for combined insertional and midsubstance Achilles repair that decreases proximal soft tissue dissection, restores musculotendinous length, and directly fixes tendon to bone in a strong, knotless fashion to allow for early mobilization and functional recovery. [Orthopedics. 2020; 43(1):e57-e64.].

Jigless knotless internal brace technique for acute Achilles tendon rupture: a case series study

Purpose

To mitigate the risk of poor wound healing and of infection associated with the open repair of Achilles tendon midsubstance ruptures, minimally invasive techniques have been developed. We report our preliminary results after reviewing our “jigless knotless internal brace technique.”

Methods

Patients were placed in prone position and a transverse 3-cm incision was made proximal to the palpable ruptured end. The proximal ruptured end was pulled out, gently debrided, and sutured using Krackow locking loops. Percutaneous sutures were crisscrossed through the distal tendon stump and looped around the Krackow sutures over the proximal stump. The ipsilateral Krackow sutures and the contralateral crisscrossed sutures were subcutaneously passed through two mini-incisions over the posterior calcaneus tuberosity and seated at the tuberosity with two 4.5-mm knotless suture anchors. All patients underwent the same post-operative rehabilitation protocol and regular follow-ups for at least 1 year.

Results

We recruited 10 patients (mean age, 37.3 years) who scored 100 points on the American Orthopaedic Foot and Ankle Society (AOFAS) scale, and who returned to their preoperative exercise levels 1-year post-operatively with no complications.

Conclusion

Our method is simple, effective, and requires no special tools. It might be a reliable option for Achilles tendon repair.

Level of evidence

III

Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears

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.

Non-operative functional treatment for acute Achilles tendon ruptures: The Leicester Achilles Management Protocol (LAMP)

OBJECTIVES

The purpose of this study is to present outcomes and objective measures of assessment for acute Achilles tendon (AT) ruptures treated with an eight-week functional dynamic treatment protocol in a VACOped^® boot with immediate full weight bearing mobilisation, the Leicester Achilles Management Protocol (LAMP).

METHODS

A prospective study of all patients treated with the LAMP with minimum 12-month follow-up was performed. Patients completed the Achilles Tendon Rupture Score (ATRS) and in the latter part of the study, objective measures of the calf muscle girth and heel raise height were obtained.

RESULTS

442 patients were treated with the LAMP. There were nine (2%) re-ruptures in the 442 non-operative treated group of patients throughout the study period. ATRS at twelve months or more were available in 234 patients and objective measures in 77 patients. The mean age was 50 years. The mean ATRS was 75.5 at an average of 23 months post injury. Men had a statistically significant higher ATRS score when compared to women (p < 0.05). There was statistically significant difference in the calf muscle girth and the heel raise height when compared to the uninjured side at 12-months post-injury (p < 0.05). These differences did not correlate with the ATRS (p > 0.05).

CONCLUSIONS

The LAMP is a simple yet effective regime for the non-operative treatment of acute AT ruptures, which can be universally adopted without the need for many resources. Compared to other studies, the overall time in the boot is less with low complication rates and similar patient reported outcomes.

Open Re-rupture of the Achilles Tendon Following Minimally Invasive Repair: A Case Report

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.

Comparison of channel-assisted minimally invasive repair and 3 common Achilles tendon restoration techniques

The present study aimed to investigate the biomechanical comparison of channel-assisted minimally invasive restoration and three common Achilles tendon restoration techniques in an in vitro model via a progressive rehabilitation program. The 42 porcine tendons were randomly assigned to the following six groups of tendons (n=7/group): Achillon, percutaneous Achilles repair system (PARS), Krackow, channel-assisted minimally invasive repair (CAMIR), CAMIR augmentation (CAMIR⁺), CAMIR-5 (repair with No. 5 Ethibond suture). There was no significant difference in elongation among groups following the first 10 loading cycles, which consisted of 20-100 N at 1 Hz. The elongation of the CAMIR group (7.51±1.77 mm) was significantly longer than the Achillon group (3.19±0.57 mm) and PARS group (3.73±0.66 mm; P<0.05) following 1,000 cycles. However, the CAMIR group exhibited no significant difference vs. the Krackow (7.32±1.09 mm) and CAMIR⁺ groups (7.11±1.50 mm) following 1,000 cycles. Following 2,000 cycles, there was no significant difference between the CAMIR-5 (7.99±1.68 mm) group, and the Achillon (3.19±0.57 mm) and PARS groups (3.73±0.66 mm). At the point of restoration construct failure, the total cycles of the CAMIR group (median, 1,000; range, 1,000-1,000) were significantly less than the Achillon group (median, 2,000; range, 2,000-2,013) and PARS group (median, 2,000; range, 2,000-2,010; P<0.05), but had no significant difference compared with the Krackow group (median, 1,000; range, 1,000-1,000) and CAMIR⁺ group 1,000 (median, 1,000; range, 1,000-1,004). There was also no significant difference between the CAMIR-5 group (median, 2,000; range, 2,000-2,000), and the Achillon group (median, 2,000; range, 2,000-2,013) and PARS group (median, 2,000; range, 2,000-2,010). Restricted by the strength of suture, the one-suture CAMIR restoration technique was weaker than the three-suture Achillon and PARS restoration techniques, but there was no significant difference with the open Krackow restoration technique, which provides a reliable mechanical strength for repairing. CAMIR has an advantage of reducing the risk of suture reactivity.

Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery

BACKGROUND

There is no consensus on the optimal technique for repairing an acute Achilles tendon rupture. The purpose of this meta-analysis was to compare the complications, subjective outcomes, and functional results between minimally invasive surgery and open repair of an Achilles tendon rupture.

METHODS

A systematic literature search of MEDLINE/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EBSCOhost, and ClinicalTrials.gov was performed. Eligible studies were randomized controlled trials (RCTs) comparing minimally invasive surgery and open repair of acute Achilles tendon ruptures. A meta-analysis was performed, while bias and the quality of the evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. The meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Eight studies, with 182 patients treated with minimally invasive surgery and 176 treated with open repair, were included. The meta-analysis showed a significantly decreased risk ratio (RR) of 0.21 (95% confidence interval [CI] = 0.10 to 0.40, p = 0.00001) for overall complications and 0.15 (95% CI = 0.05 to 0.46, p = 0.0009) for wound infection after minimally invasive surgery. Patients treated with minimally invasive surgery were more likely to report good or excellent subjective results (RR = 1.18, 95% CI = 1.04 to 1.33, p = 0.009). No differences between groups were found with respect to reruptures, sural nerve injury, return to preinjury activity level, time to return to work, or ankle range of motion. The overall quality of evidence was generally low because of a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients.

CONCLUSIONS

There was a significantly decreased risk of postoperative complications, especially wound infection, when acute Achilles tendon rupture was treated with minimally invasive surgery compared with open surgery. Patients treated with minimally invasive surgery were significantly more likely to report a good or excellent subjective outcome. Current evidence is associated with high heterogeneity and a considerable risk of bias.

LEVEL OF EVIDENCE

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

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update

BACKGROUND

Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy.

METHODS

Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated.

RESULTS

Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous.

CONCLUSIONS

The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Achillon versus open surgery in acute Achilles tendon repair

BACKGROUND

Open Achilles tendon repairs (OATR) are associated with high complication rates. Minimally invasive surgery (MIS) techniques like the Achillon Achilles tendon repair (AATR) were developed to reduce this. We performed a systematic review and meta-analysis to compare OATR with AATR.

METHODS

We performed an extensive literature search including all studies that compared the two techniques. Outcomes assessed included overall complication rate, re-rupture rate, sural nerve injury, wound length, The American Orthopaedic Foot and Ankle Scores (AOFAS) scores and return to sports.

RESULTS

Eight studies were suitable for inclusion totalling 210 patients in the AATR group vs 233 patients in the OATR group. Total complication rates were significantly reduced in the Achillon patients with odd ratio of 0.14 (CI 95%, 0.08-0.27, P<0.00001) in favour. There were no significant differences in re-rupture rate, sural nerve injury, return to sports and AOFAS scores following repair between the two groups.

CONCLUSIONS

AATR has fewer overall complications compared with OATR. It should be considered as an alternative to open surgical repair.

Outcomes of Limited Open Achilles Repair Using Modified Ring Forceps

Background

The optimal treatment of acute Achilles tendon ruptures remains controversial. When surgical repair is undertaken, the reported rate of infections and wound-healing complications ranges from 2% to 5%. Meta-analyses have demonstrated that minimally invasive approaches have equivalent rerupture rates, a significantly lower risk of superficial infections, and higher patient satisfaction rates compared with traditional open Achilles repair techniques.

Purpose

To review the clinical outcomes of acute, limited open Achilles tendon repair using modified ring forceps and to analyze functional results using foot and ankle-specific outcome measures.

Study Design

Case series; Level of evidence, 4.

Methods

The clinical records of 32 consecutive patients (mean age, 44 years) with 33 acute Achilles tendon ruptures were retrospectively reviewed. All patients underwent limited open repair with modified ring forceps through a 2- to 3-cm midline incision. Suture placement into the tendon stumps was guided using a pair of ring forceps bent 30°. Three No. 2 nonabsorbable sutures were placed in the proximal and distal segments, the tendon ends were reapproximated, and the sutures were tied to secure the tendon. Outcomes from a 10-cm visual analog scale (VAS), the Foot and Ankle Ability Measure (FAAM), and the Victorian Institute of Sport Assessment-Achilles (VISA-A) were assessed.

Results

At final follow-up (mean, 42.1 months [range, 6-90 months]), 31 of 32 patients (33 Achilles tendons) reported no pain in their Achilles, with a mean Achilles VAS score of 0.7 ± 4.2 of 100. The mean postoperative VISA-A score was 82.3 ± 19.5 of 100. The mean FAAM activities of daily living and sports subscores were 96.5% ± 5.2% and 85.1% ± 21.2%, respectively. Regarding current functional level, 19 of 33 tendons (57.6%) were rated as "normal," 10 (30.3%) as "nearly normal," and 4 (12.1%) as "abnormal"; none were rated as "severely abnormal." There was 1 case (3.0%) of a superficial infection; there were no cases of deep infections, sural neuritis, or reruptures. The cost of the modified ring forceps technique is 5.3 to 12.1 times less than commercially available devices.

Conclusion

Limited open Achilles repair with modified ring forceps provides an economical repair with excellent pain relief, favorable functional outcomes, and a very low complication rate at midterm follow-up.

Outcome of Percutaneous Fixation of Acute Achilles Tendon Ruptures

BACKGROUND

Conservative treatment of an acute Achilles rupture remains a viable and acceptable option as does surgical fixation, with open and percutaneous repair consisting the main operative techniques. The purpose of this study was to compare the outcomes and complication rates of open versus percutaneous surgical procedures.

METHODS

From 2009 to 2016, 131 patients were admitted to our department with clinically and radiologically confirmed acute Achilles tendon ruptures. Of those, 82 patients met our inclusion criteria and were randomized into 2 groups, group A (open repair) and group B (percutaneous suturing). Suture equipment was the same for both groups. All patients followed the same rehabilitation protocol. Functional evaluation was made using American Orthopaedic Ankle & Foot Society (AOFAS) hindfoot and Achilles tendon Total Rupture Score (ATRS) questionnaires at the 12-month follow-up. Ankle range of motion (ROM), return-to-work time, and complication rates were additionally measured.

RESULTS

Both techniques had similar results regarding complication rates and return-to-work time. The major complication in group A was superficial infection (7%) and skin necrosis (3%), whereas 3 patients in group B developed paresthesias due to sural nerve entrapment. Patients in group B had better AOFAS hindfoot (96/100) and ATRS (95/100) scores, but the difference was not significant. ROM was similar in both groups at the 12-month follow-up.

CONCLUSION

Percutaneous suturing seems to be a safe and effective technique that offers good functional outcomes and low complication rates in patients with acute Achilles tendon ruptures who elect to have surgery.

LEVEL OF EVIDENCE

Level II, prospective case series.

Outcome after operative treatment for chronic versus acute Achilles tendon rupture - A comparative analysis

BACKGROUND

This study compared outcomes after treatment of acute Achilles tendon (AT) rupture via percutaneous suturing, with those after chronic AT rupture treated via open reconstruction.

METHODS

This retrospective study included 30 patients who underwent either percutaneous suturing for acute AT rupture (group AR, n=16) or open reconstruction for chronic AT rupture (group CR, n=14). Function was evaluated by calf muscle circumference, and endurance through isokinetic measurement and single-leg heel-rise test. Score evaluation included AT Total Rupture Score, Victorian Institute of Sports Assessment-Achilles questionnaire, and visual analogue scale pain score. Postoperative tendon thickness was measured using ultrasonography and MRI.

RESULTS

Follow-up was conducted 4.97±1.79 years postoperatively. The groups were similar in age and body mass index. There was no significant difference between groups in calf circumference, isokinetic measurement, heel-rise test, and score evaluation. There was significantly less mediolateral tendon thickening in group AR compared with group CR on ultrasonography (p=0.01) and MRI (p=0.001).

CONCLUSIONS

Open reconstruction for chronic AT rupture may result in comparable clinical and functional outcomes, but a thicker tendon compared with percutaneous suturing after acute AT rupture.

Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair

PURPOSE

Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair.

METHODS

A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included.

RESULTS

One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment.

CONCLUSION

Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician.

LEVEL OF EVIDENCE

II.

A Percutaneous Knotless Technique for Acute Achilles Tendon Ruptures

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.

5-year results of the 1.5cm incision Achilles tendon repair

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.

Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures

Background

Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading.

Methods

Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure.

Results

Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively).

The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens.

Conclusion

The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.

Effect of Suture Caliber and Number of Core Strands on Repair of Acute Achilles Ruptures: A Biomechanical Study

BACKGROUND

Controversy exists regarding the ideal Achilles rupture treatment; however, operative treatment is considered for athletes and active patients. The ideal repair construct is evolving, and the effect of suture caliber or number of core strands has not been studied.

METHODS

Simulated mid-substance Achilles ruptures were performed in 24 cadavers. Specimens were randomized to three 6-core-strand style repair constructs: (1) 4 No. 2 sutures and two 2-mm tapes (2T); (2) 2 No. 2 sutures and four 2-mm tapes (4T); (3) 12 (double-6-strand) strand repair (12 No. 2-0 sutures [12S]). Repairs were subjected to a cyclic loading protocol representative of postoperative rehabilitation. These data were compared to a previously published standard open repair technique (6-core strands with No. 2 sutures) on 9 specimens tested under the same conditions.⁶ Results: No significant elongation differences were observed between the repair groups and the previously published standard repair group in the first 2 stages of the simulated rehabilitation protocol. Both the 2T and 12S repairs survived a significantly greater number of cycles to failure ( P = 0.0005, P = 0.0267, respectively) and had a significantly higher failure load ( P = .0005, P = .0118, respectively) compared to the previously published data. These 2 constructs consistently survived the advanced stages of the simulated rehabilitation protocol. The majority of repairs failed at the knots.

CONCLUSIONS

In this study, the 2T and 12S constructs survived the later stages of our simulated rehabilitation protocol, suggesting that they may be able to accommodate a more aggressive clinical rehabilitation protocol. Substituting suture-tape for 2 core strands or doubling the core strands with a smaller-caliber suture created a biomechanically stronger construct.

CLINICAL RELEVANCE

Achilles repair with an added nonabsorbable, high-tensile strength tape allowed for a stronger construct that may allow for a more aggressive, early rehabilitation protocol and earlier return to function.

Achilles Tendon Open Surgical Treatment With Platelet-Rich Fibrin Matrix Augmentation: Biomechanical Evaluation

The relationship between surgical technique and ankle biomechanical properties after surgery for acute rupture of the Achilles tendon (ATR) has not yet been fully investigated. Platelet-rich fibrin (PRF) matrices seem to play a central role in the complex processes of tendon healing. Our aim was to analyze the biomechanical characteristics, stiffness, and mechanical work of the ankle during walking in patients who had undergone surgery after ATR with and without PRF augmentation. We performed a retrospective review of all consecutive patients who had been treated with surgical repair after ATR. Of the 20 male subjects enrolled, 9 (45%) had undergone conventional open repair of the Achilles tendon using the Krackow technique (no-PRF) and 11 (55%) had undergone surgery with PRF augmentation. An additional 8 healthy subjects were included as a control group. A gait analysis evaluation was performed at 6 months after surgery. The percentage of the stance time of the operated leg, double-support time of the healthy leg, and net work of the ankle during the gait cycle showed statistically significant differences between the no-PRF and the healthy group (p < .005). No differences were found between the PRF and healthy groups. Treatment with suture and PRF augmentation could result in significant functional improvements in term of efficiency of motion.

Acute Achilles Rupture Percutaneous Repair: Approach, Materials, Techniques

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.

Outcomes and complications of percutaneous versus open repair of acute Achilles tendon rupture: A meta-analysis

BACKGROUND

Acute Achilles tendon rupture (AATR) is a frequent injury occurring dominantly in young to middle-aged males. Outcomes and complications between percutaneous and open repair are still controversial. Thus, the purpose of this meta-analysis is to evaluate the outcomes and complications of these two operative methods.

MATERIALS AND METHODS

We searched multiple databases: PubMed, Web of Science, EMBASE and the Cochrane Library up to October 2016. Two reviewers independently screened the studies for eligibility, evaluated the quality and extracted data from eligible studies, with confirmation by cross-checking. The major results and conclusions were concluded, and the different complication rates and functional outcomes were compared. Meta-analysis was processed by Rev Man 5.3 software.

RESULTS

Five randomized controlled trials (RCTs) and seven retrospective cohort studies involving 815 patients met the inclusion criteria. The sural nerve injury rate in the percutaneous group was significantly higher (RR = 3.52, 95%CI 1.45 to 8.57, P = 0.006). However, deep infection rate in the open group was higher (RR = 0.33, 95%CI 0.11 to 0.96, P = 0.04) and subgroup analysis of five RCTs showed no significant difference (RR = 0.42, 95%CI 0.09 to 2.10, P = 0.29). No significant difference was seen regarding the rate of re-rupture. The time of operation in the percutaneous group was shorter (RR = -1.99, 95%CI -3.81 to -0.80, P = 0.001). American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score showed statistically different in the two groups. Other functional outcomes were similar in the two groups.

CONCLUSIONS

Percutaneous repair has the advantages of operation time, deep infection and AOFAS score. The functional outcomes were similar in two treatment groups except AOFAS score. Despite the higher incidence of sural nerve injury, we still believe that percutaneous repair is superior to open repair for treating AATR.

Achilles tendon injuries

PURPOSE OF REVIEW

The purpose of this study is to review the current literature of Achilles tendon injuries, specifically chronic tendinopathy and acute ruptures in regard to etiology, diagnosis, treatment options, and outcomes.

RECENT FINDINGS

The incidence of Achilles tendon injuries is increasing, but the necessity for surgical intervention is decreasing due to improved conservative therapies, which may provide comparable outcomes without the implied surgical risk. If surgery is undertaken, no difference has been noted between open and minimally invasive techniques. The majority of patients are able to return to pre-injury level of activity, with the elite athlete as an unfortunate exception. Achilles injuries can be devastating injuries, but if addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality implemented. Further research is needed into the etiology, potential preventative measures, and longer-term outcomes of the different treatment options for wide range of Achilles pathology.

Management of acute Achilles tendon rupture with tendon-bundle technique

Objective * These authors contributed equally to this work. To explore tendon-bundle technique for treating Achilles tendon rupture with no defects. Methods Patients with full unilateral Achilles tendon rupture with no defects were included. The Achilles tendon medial edge surgical repair approach was used, revealing horsetail-like rupture bundles. Tendon bundles were anatomically realigned and repaired end-to-end using 5-0 sutures. Patients were followed-up for 1 year, and assessed for differences between the repaired versus healthy limb. Results Out of 24 patients (18 male, 6 female; aged 19-56 years) at 1 year following surgery, mean American Orthopaedic Foot and Ankle Society score was 92.4 ± 5.9; mean differences between the surgically repaired versus contralateral side in dorsiflexion and plantarflexion angle were 3.5 ± 2.3° and 5.6 ± 3.2°, respectively; mean difference in calf circumference between the two sides was 0.9 ± 0.5 cm; and mean increase in Achilles tendon width versus the healthy side was 0.8 ± 0.2 cm. By 1 year post-surgery, there were no significant between-side differences in dorsiflexion and plantarflexion angle, or calf circumference. Conclusions Tendon-bundle surgery resulted in good ankle function restoration and low complication rates. Tendon-bundle surgery may reduce blood supply destruction and maximally preserve Achilles tendon length, and may be effective for treating Achilles tendon rupture with no defects.