Complications of the treatment of Achilles tendon ruptures

The learning curve for minimally invasive Achilles repair using the "lumbar puncture needle and oval forceps" technique

INTRODUCTION

An acute Achilles tendon rupture represents a common tendon injury, and its operative methods have been developed over the years. This study aimed to quantify the learning curve for the minimally invasive acute Achilles tendon rupture repair.

METHODS

From May 2020 to June 2022, sixty-seven patient cases who received minimally invasive tendon repair were reviewed. Baseline data and operative details were collected. The cumulative summation (CUSUM) control chart was used for the learning curve analyses. Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score, and visual analog scale (VAS) at 3/6/9/12 months were calculated to assess the clinical outcomes.

RESULTS

Thirty-six cases underwent at least a year of follow up and were enrolled in this study. The gender ratio and average age were 80.5% and 32.5 years. The linear equation fitted well (R2 = 0.95), and CUSUM for operative time peaked in the 12th case, which was divided into the learning phase (n = 12) and master phase (n = 24). No significant difference was detected between the two groups in clinical variables, except for the operative time (71.1 ± 13.2 min vs 45.8 ± 7.2 min, p = 0.004). Moreover, we detected one case with a suture reaction and treated it properly.

CONCLUSION

Minimally invasive Achilles repair provides an opportunity for early rehabilitation. Notably, the learning curve showed that the "lumbar puncture needle and oval forceps" technique was accessible to surgeons.

Risk factors and clinical characteristics of surgical site infections in athletes undergoing Achilles tendon repair surgery

Achilles tendon ruptures are common in athletes, requiring surgical intervention. However, the risk of surgical site infections (SSIs) post-surgery poses significant challenges. This study aims to analyse the risk factors and microbial aetiology associated with SSIs in athletes undergoing Achilles tendon repair. A comprehensive retrospective analysis was conducted from May 2021 to July 2023. The study included 25 patients with SSIs (case group) and 50 patients without SSIs (control group) post Achilles tendon repair surgery. Inclusion criteria encompassed patients with medically confirmed Achilles tendon ruptures who underwent surgical repair. Exclusion criteria included prior tendon pathologies and significant chronic illnesses. Diagnostic criteria for SSIs involved symptoms like elevated body temperature and localized tenderness, along with laboratory confirmations such as positive microbiological cultures. The study utilized VITEK® 2 for bacterial identification and involved statistical analyses like univariate and multivariate logistic regression. The study identified Staphylococcus aureus as the primary pathogen in SSIs. Significant risk factors included lack of prophylactic antibiotic use, presence of diabetes, open wounds and prolonged surgery duration. Univariate analysis revealed stark contrasts in these factors between infected and non-infected groups, while multivariate analysis underscored their importance in SSI development. S. aureus emerged as the predominant pathogen in SSIs post Achilles tendon repair. Critical risk factors such as absence of prophylactic antibiotics, diabetes, open wounds and extended surgery duration play a vital role in SSIs. Addressing these factors is essential for better postoperative outcomes in Achilles tendon repair surgeries.

Imaging of the Peripheral Nerves of the Lower Extremity

Continued advancements in magnetic resonance (MR) neurography and ultrasound have made both indispensable tools for the workup of peripheral neuropathy. Ultrasound provides high spatial resolution of superficial nerves, and techniques such as "sonopalpation" and dynamic maneuvers can improve accuracy. Superior soft tissue contrast, ability to evaluate both superficial and deep nerves with similar high resolution, and reliable characterization of denervation are strengths of MR neurography. Nevertheless, familiarity with normal anatomy, anatomic variants, and common sites of nerve entrapment is essential for radiologists to use both MR neurography and ultrasound effectively.

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Rupture: A Propensity Score-Matched Analysis of a Large National Dataset

Background

No consensus exists regarding the superiority of operative versus nonoperative management for Achilles tendon ruptures, as multiple randomized controlled trials conducted since the advent of early mobilization protocols have found outcomes for these 2 interventions to be more similar than were previously held.

Purpose

To use a large national database to (1) compare reoperation and complication rates between operative and nonoperative treatment of acute Achilles tendon ruptures and (2) evaluate trends in treatment and cost over time.

Study Design

Cohort study; Level of evidence, 3.

Methods

The MarketScan Commercial Claims and Encounters database was used to identify an unmatched cohort of 31,515 patients who sustained primary Achilles tendon ruptures between 2007 and 2015. Patients were stratified into operative and nonoperative treatment groups, and a propensity score-a matching algorithm-was used to establish a matched cohort of 17,996 patients (n = 8993 per treatment group). Reoperation rates, complications, and aggregate treatment costs were compared between groups with an alpha level of .05. A number needed to harm (NNH) was calculated from the absolute risk difference in complications between cohorts.

Results

The operative cohort experienced a significantly larger total number of complications within 30 days of injury (1026 vs 917; P = .0088). The absolute increase in cumulative risk was 1.2% with operative treatment, which resulted in an NNH of 83. Neither 1-year (1.1% [operative] vs 1.3% [nonoperative]; P = .1201) nor 2-year reoperation rates (1.9% [operative] vs 2% [nonoperative]; P = .2810) were significantly different. Operative care was more expensive than nonoperative care at 9 months and 2 years after injury; however, there was no difference in cost between treatments at 5 years. Before matching, the rate of surgical repair for Achilles tendon rupture remained stable, from 69.7% to 71.7% between 2007 and 2015, indicating little change in practice in the United States.

Conclusion

Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. Operative management was associated with an increased risk of complications and higher initial costs, which dissipated over time. Between 2007 and 2015 the proportion of Achilles tendon ruptures managed operatively remained similar despite increasing evidence that nonoperative management of Achilles tendon rupture may provide equivalent outcomes.

Microfragmented Adipose Tissue (M-FATS) for Improved Healing of Surgically Repaired Achilles Tendon Tears: A Preliminary Study

INTRODUCTION

Tendon healing is a complicated process that results in inferior structural and functional properties when compared with healthy tendon; the purpose of this study was to assess the effects of the adjunct of microfragmented adipose tissue (M-FATS) after the suture of a series of Achilles tendons.

METHODS

After complete Achilles tendon tear, 8 patients underwent open suture repair in conjunction with perilesional application of a preparation of M-FATS rich in mesenchymal stem cells. Results were compared with a similar group of patients treated with conventional open suture. Outcomes were evaluated based on range of motion, functional recovery, and complications according to the American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Disability Index (FADI). Achilles tendons were examined by ultrasound (US) at 3 months.

RESULTS

The AOFAS and FADI scores showed no differences between the 2 groups. US evaluation showed quicker tendon remodeling in the M-FATS group. Adverse events were not documented for both procedures.

CONCLUSIONS

The combined application of derived M-FATS for tendon rupture is safe and presents new possibilities for enhanced healing.

LEVELS OF EVIDENCE

Level IIIb: Case control study.

One-stage reconstruction of the massive overlying skin and Achilles tendon defects using a free chimeric anterolateral thigh flap with fascia lata

BACKGROUND

Treatment for large defects in the non-weight-bearing Achilles tendon and soft tissues remains a reconstructive challenge. The free composite anterolateral thigh flap (ALT) with fascia lata (FL) has been indicated in the single-stage reconstruction of the Achilles tendon and soft tissue defect and this technique remain some disadvantages, such as the inability to perform primary flap thinning, requiring secondary flap thinning, and the delayed normalization of the range of motion of the ankle joint. The free chimeric ALT flap with FL was introduced as a novel alternative with many advantages in reconstructing the Achilles tendon and soft tissue defects. This paper reports the reconstruction of the massive Achilles tendon and overlying skin defects using free chimeric ALT flaps with FL.

METHODS

From June 2017 to October 2020, we performed on a series of 5 patients receiving free chimeric ALT flaps with FL to reconstruct the Achilles tendon and soft tissue defects. The age of patients ranged from 43 to 62 years old. All five patients had full-layer defects of the Achilles tendon with infection. The sizes of the skin defects ranged from 6 × 4 cm to 12 × 10 cm. The perforators from the descending branch of the lateral circumflex femoral arteries are located using a handheld Doppler. The perforators help to design the outline of the ALT flap and fascia flap. The skin flap was thinned under microscopy if the flap was too thick. The anastomosis was accomplished before insetting the flaps into the defect.

RESULTS

The size of the ALT flap ranged from 10 × 5 cm to 15 × 12 cm, and the size of the FL flap ranged from 7 × 4 cm to 10 × 8 cm. The mean perforator length for the skin flap and fascia lata was 3.3 cm (range, 2.5-5.0 cm) and 5.3 cm (range, 3.5-7.0 cm), respectively. Four patients received skin flap thinning up to 57%-79% of the flap thickness, while one patient did not need to debulk. The thickness of the ALT flap ranged from 6 to 13 mm. All the flaps survived completely and postoperative courses were uneventful without any complications. The follow-up time ranged from 12 to 51 months. All patients were able to stand and ambulate, and they were satisfied with the reconstructive results.

CONCLUSIONS

The free thin chimeric ALT with FL flap is appeared to be an appropriate treatment for the massive Achilles tendon and overlying skin defects. This may be a practical approach to improve the functional outcomes of patients with infected massive Achilles tendon and overlying skin defects.

The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture

PURPOSE

Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions.

METHODS

From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture.

RESULTS

Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043).

CONCLUSIONS

The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.

Retrocalcaneal Enthesophyte Resection With Functional Lengthening of the Achilles Tendon and Buried Knot Technique: A Case Series

Retrocalcaneal exostosis can be debilitating and in severe cases, surgical resection is indicated. Complications can arise from surgical resection of the exostosis and reattachment of the Achilles tendon, including irritation of the suture knot, recurrence of the bony prominence, and dehiscence. The use of a buried knot technique with functional lengthening of the Achilles tendon and gastroc-soleal muscle complex can minimize these complications. Complete detachment of the Achilles tendon allows for aggressive and thorough resection of the exostosis and functional lengthening with reattachment. The buried cruciate knot technique allows for firm reattachment with buried knots to prevent soft tissue irritation. A total of fourteen patients (14 limbs) underwent retrocalcaneal enthesophyte resection with functional Achilles tendon lengthening, (8/14) of which had difficultly wearing shoe gear, (10/14) had edema, and (2/14) had erythema preoperatively. Postoperatively, (11/14) of patients returned to full activities and sports, and (11/14) returned to normal shoe gear. Complications included (1/14) of patients with Achilles tendon avulsion and (3/14) of patients with surgical site dehiscence requiring revisional surgery. Overall, this technique helps prevent short-term complications and long-term recurrence due to the functional lengthening mitigating insertional forces on the Achilles tendon.

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.

A simple approach for determining tendon limb length in open Achilles lengthening: technical note

Estimating the appropriate tendon length and associated skin incision needed to achieve a plantigrade foot without compromising function are essential steps in open Achilles tendon lengthening. Here we describe a technique using basic surgical instruments referencing anatomic landmarks without the need for radiographs. The center of ankle rotation in the sagittal plane is found referencing the tip of the medial malleolus. This point is translated to the plantar surface of the foot, and a straight instrument in line with the foot is used to make a mark at the posterior calcaneal fat pad. The straight instrument is then rotated (representing the plantar surface of the foot) as if dorsiflexing the ankle along the axis of the transposed tibiotalar joint from a plantar-flexed position to the desired final position and a second mark is made at the posterior heel. The distance between the marks is measured, representing the amount of Achilles lengthening required. The skin incision and tendon limb lengths area a sum of the operative correction and the amount of desired tendon overlap, typically 2 cm of tendon overlap is optimal to allow for suture fixation, ensure tendon healing, and maintain the integrity of the repair. A Z-type lengthening is then performed using this tendon limb length. This technique allows an accurate and simple approach to lengthening the Achilles tendon. In this way the ideal tendon limb length is selected to optimize function while minimizing incision length, associated wound complications, inadequate lengthening, and overlengthening. Level of evidence: Technical note, Level V.

Genome-wide transcriptome analysis reveals equine embryonic stem cell-derived tenocytes resemble fetal, not adult tenocytes

BACKGROUND

Tendon injuries occur frequently in human and equine athletes. Treatment options are limited, and the prognosis is often poor with functionally deficient scar tissue resulting. Fetal tendon injuries in contrast are capable of healing without forming scar tissue. Embryonic stem cells (ESCs) may provide a potential cellular therapeutic to improve adult tendon regeneration; however, whether they can mimic the properties of fetal tenocytes is unknown. To this end, understanding the unique expression profile of normal adult and fetal tenocytes is crucial to allow validation of ESC-derived tenocytes as a cellular therapeutic.

METHODS

Equine adult, fetal and ESC-derived tenocytes were cultured in a three-dimensional environment, with histological, morphological and transcriptomic differences compared. Additionally, the effects on gene expression of culturing adult and fetal tenocytes in either conventional two-dimensional monolayer culture or three-dimensional culture were compared using RNA sequencing.

RESULTS

No qualitative differences in three-dimensional tendon constructs generated from adult, fetal and ESCs were found using histological and morphological analysis. However, genome-wide transcriptomic analysis using RNA sequencing revealed that ESC-derived tenocytes' transcriptomic profile more closely resembled fetal tenocytes as opposed to adult tenocytes. Furthermore, this study adds to the growing evidence that monolayer cultured cells' gene expression profiles converge, with adult and fetal tenocytes having only 10 significantly different genes when cultured in this manner. In contrast, when adult and fetal tenocytes were cultured in 3D, large distinctions in gene expression between these two developmental stages were found, with 542 genes being differentially expressed.

CONCLUSION

The information provided in this study makes a significant contribution to the investigation into the differences between adult reparative and fetal regenerative cells and supports the concept of using ESC-derived tenocytes as a cellular therapy. Comparing two- and three-dimensional culture also indicates three-dimensional culture as being a more physiologically relevant culture system for determining transcriptomic difference between the same cell types from different developmental stages.

Age and Tightness of Repair Are Predictors of Heel-Rise Height After Achilles Tendon Rupture

Background:

Achilles tendon rupture leads to weakness of ankle plantarflexion. Treatment of Achilles tendon rupture should aim to restore function while minimizing weakness and complications of management.

Purpose:

To determine the influence of factors (age, sex, body mass index [BMI], weight, time from injury to operative repair, and tightness of repair) in the initial surgical management of patients after an acute Achilles tendon rupture on 12-month functional outcome assessment after percutaneous and minimally invasive repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

From May 2012 to January 2018, patients sustaining an Achilles tendon rupture receiving operative repair were prospectively evaluated. Tightness of repair was quantified using the intraoperative Achilles tendon resting angle (ATRA). Heel-rise height index (HRHI) was used as the primary 12-month outcome variable. Secondary outcome measures included Achilles tendon total rupture score (ATRS) and Tegner score. Stepwise multiple regression was used to create a model to predict 12-month HRHI.

Results:

A total of 122 patients met the inclusion criteria for data analysis (mean ± SD age, 44.1 ± 10.8 years; 78% male; mean ± SD BMI, 28.1 ± 4.3 kg/m²). The elapsed time to surgery was 6.5 ± 4.0 days. At 12-month follow-up, patients had an HRHI of 82% ± 16% and performed 82% ± 17% of repetitions compared with the noninjured side. Participants had a mean ATRS of 87 ± 15 and a median Tegner score of 5 (range, 1-9), with a reduction in Tegner score of 2 from preinjury levels. The relative ATRA at 12 months was –4.8° ± 3.9°. Multiple regression identified younger age (B = ±0.006; P < .001) and greater intraoperative ATRA (B = 0.005; P = .053) as predictors of more symmetrical 12-month HRHI (R² = 0.19; P < .001; n = 120).

Conclusion:

Age was found to be the strongest predictor of outcome after Achilles tendon rupture. The most important modifiable risk factor was the tightness of repair. It is recommended that repair be performed as tight as possible to optimize heel-rise height 1 year after Achilles tendon rupture and possibly to reduce tendon elongation.

Standardised virtual fracture clinic management of Achilles tendon ruptures is safe and reproducible

BACKGROUND

Traditional fracture clinics are some of the busiest clinics in a hospital, often with significant patient waiting times and delays. The use of virtual fracture clinic (VFC) for the management of certain injuries to reduce the workload on the traditional fracture clinic, in addition to reducing costs is growing in popularity. The tendoachilles is the most frequently ruptured tendon in the body but despite this, management remains a keenly debated topic.

METHODS

All adult patients referred to the VFC with an actual or suspected Achilles tendon rupture were identified between January 2015 to October 2017.

RESULTS

This study found that patient with and acute achilles tendon ruptures managed according to a standardised VFC protocol had a re-rupture rate of 3.82%.

CONCLUSIONS

One of the advantages of a VFC model that is standardised, initiated in the ED, is that it has no variation in outcome seen in our patient group.

A comparison of three methods of skin closure following repair of Achilles tendon rupture

Meticulous skin closure is required to avoid wound problems after Achilles tendon surgery. The purpose of our study was to compare postoperative complication rate, operation time, clinical outcome and patient satisfaction with the wound among two topical skin adhesives (2-octyl cyanoacrylate and n-butyl cyanoacrylate) and conventional nylon skin sutures in Achilles tendon repair surgery. We retrospectively reviewed the records 122 consecutive patients (40 patient in nylon skin suture, 43 patients in 2-octyl cyanoacrylate and 39 patients in n-butyl cyanoacrylate) who underwent surgical repair for acute Achilles tendon rupture between 2012 and 2016. The primary outcome measure was the development of complications in the wound. Secondary outcome measures included the operative time, the Achilles Tendon Total Rupture Score (ATRS) and patient satisfaction with the wound. There was no difference in complication rate in the wound (p = 0.694) and in ATRS (p = 0.824) among patients in the three groups. Mean operative time in nylon skin suture group was significantly longer than in the 2-octyl cyanoacrylate group and n-butyl cyanoacrylate group (p = 0.018 and p = 0.002, respectively). Patient satisfaction in the 2-octyl cyanoacrylate and n-butyl cyanoacrylate groups was significantly higher than in the nylon skin suture group (p = 0.015 and 0.018, respectively). The use of 2-octyl cyanoacrylate and n-butyl cyanoacrylate topical skin adhesives for skin closure following repair of Achilles tendon rupture has equivalent effectiveness and safety compared to conventional nylon skin suture, but higher patient satisfaction. Despite its higher cost, these topical skin adhesives are viable alternatives for wound closure in patients who regard cosmetic outcomes as important.

Foot and Ankle Surgery: Common Problems and Solutions

Participation in sports activity has increased significantly during the last several decades. This phenomenon has exposed orthopedic sports medicine surgeons to new challenges regarding the diagnosis and management of common sport-related injuries. Arthroscopy is becoming more commonly used in many of the surgical procedures for these injuries and carries the risk of complications. Wound and nerve complications make up the bulk of complications in most procedures. This article describes these complications associated with the common surgical procedures related to foot and ankle sport-related injuries and how to address and prevent them.

Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures

PURPOSE

The aim of this study was to perform a long-term follow-up of patients treated for an Achilles tendon re-rupture, using established outcome measurements for tendon structure, lower extremity function and symptoms, and to compare the results with those for the uninjured side. A secondary aim was to compare the outcome with that of patients treated for primary ruptures. The hypotheses were that patients with a re-rupture recover well, and have similar long-term outcome as primary ruptures.

METHODS

Twenty patients (4 females) with a mean (SD) age of 44 (10.9) years, ranging from 24 to 64, were included. The patients were identified by reviewing the medical records of all Achilles tendon ruptures at Sahlgrenska University Hospital and Kungsbacka Hospital, Sweden, between 2006 and 2016. All patients received standardised surgical treatment and rehabilitation. The mean (SD) follow-up was 51 (38.1) months. A test battery of validated clinical and functional tests, patient-reported outcome measurements and measurements of tendon elongation were performed at the final follow-up. This cohort was then compared with the 2-year follow-up results from a previous randomised controlled trial of patients treated for primary Achilles tendon rupture.

RESULTS

There were deficits on the injured side compared with the healthy side in terms of heel-rise height (11.9 versus 12.5 cm, p = 0.008), repetitions (28.5 versus 31.7, p = 0.004) and drop-jump height (13.2 versus 15.1 cm, p = 0.04).  There was a significant difference in calf circumference (37.1 versus 38.4 cm, p =< 0.001) and ankle dorsiflexion on the injured side compared with the healthy side (35.3° versus 40.8°, p = 0.003). However, no significant differences were found in terms of tendon length 22.5 (2.5) cm on the injured side and 21.8 (2.8) cm on the healthy side. Compared with primary ruptures, the re-rupture cohort obtained significantly worse results for the Achilles tendon total rupture score, with a mean of 78 (21.2) versus 89.5 (14.6) points, (p = 0.007). The re-ruptures showed a higher mean LSI heel-rise height, 94.7% (9.3%) versus 83.5% (11.7%) (p = < 0.0001), and superior mean LSI eccentric-concentic power, 110.4% (49.8%) versus 79.3% (21%) (p = 0.001), than the primary ruptures.

CONCLUSION

The results of this study indicate that patients with an Achilles tendon re-rupture had continued symptoms and functional deficits on the injured side, after a long-term follow-up. Patients with an Achilles tendon re-rupture had worse patient-reported outcomes but similar or superior functional results compared with patients with primary ruptures.

LEVEL OF EVIDENCE

Case series, Level IV.

Therapeutic Effects of Doxycycline on the Quality of Repaired and Unrepaired Achilles Tendons

BACKGROUND

Achilles tendon tears are devastating injuries, especially to athletes. Elevated matrix metalloproteinase (MMP) activity after a tendon injury has been associated with deterioration of the collagen network and can be inhibited with doxycycline (Doxy).

HYPOTHESIS

Daily oral administration of Doxy will enhance the histological, molecular, and biomechanical quality of transected Achilles tendons. Additionally, suture repair will further enhance the quality of repaired tendons.

STUDY DESIGN

Controlled laboratory study.

METHODS

Randomized unilateral Achilles tendon transection was performed in 288 adult male Sprague-Dawley rats. The injured tendons were either unrepaired (groups 1 and 2) or surgically repaired (groups 3 and 4). Animals from groups 2 and 4 received Doxy daily through oral gavage, and animals from groups 1 and 3 served as controls (no Doxy). Tendons were harvested at 1.5, 3, 6, and 9 weeks after the injury (n = 18 per group and time point). The quality of tendon repair was evaluated based on the histological grading score, collagen fiber orientation, gene expression, and biomechanical properties.

RESULTS

In surgically repaired samples, Doxy enhanced the quality of tendon repair compared with no Doxy ( P = .0014). Doxy had a significant effect on collagen fiber dispersion, but not principal fiber angle. There was a significant effect of time on the gene expression of MMP-3, MMP-9 and TIMP1, and Doxy significantly decreased MMP-3 expression at 9 weeks. Doxy treatment with surgical repair increased the dynamic modulus at 6 weeks but not at 9 weeks after the injury ( P < .001). Doxy also increased the equilibrium modulus and decreased creep strain irrespective of the repair group. Doxy did not have a significant effect on the histology or biomechanics of unrepaired tendons.

CONCLUSION

The findings indicate that daily oral administration of Doxy accelerated matrix remodeling and the dynamic and equilibrium biomechanics of surgically repaired Achilles tendons, although such enhancements were most evident at the 3- to 6-week time points.

CLINICAL RELEVANCE

The inhibition of MMPs at the optimal stage of the repair process may accelerate Achilles tendon repair and improve biomechanical properties, especially when paired with surgical management.

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon Surgery Wound Complications

INTRODUCTION

Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here, we describe coverage of a series of posterior heel and Achilles wounds via simple, local tissue transfer, called a bipedicle fasciocutaneous flap. This flap can be performed by an orthopaedic foot and ankle surgeon, without resources of tertiary/specialized care or microvascular support.

METHODS

Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 2 was a heel venous stasis ulcer with calcaneal exposure in a diabetic patient with vasculopathy. Case 3 was a patient with wound breakdown following midsubstance Achilles tendon repair. All three cases were treated with a single-stage bipedicle local tissue transfer for posterior ankle and heel wound complications.

RESULTS

All 3 patients demonstrated complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site after surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear.

CONCLUSIONS

The bipedicled fasciocutaneous flap described here offers a predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap can be performed with short operative times and can be customized to facilitate defect coverage. The flap is durable to withstand local tissue stresses required for early ambulation. Despite its reliability, patients require careful follow-up to manage underlying comorbid conditions that may complicate wound healing.

LEVELS OF EVIDENCE

Level IV: Case series.

Endoscopy-Assisted Achilles Tendon Reconstruction With a Central Turndown Flap and Semitendinosus Augmentation

BACKGROUND

The objective of this study was to report the results of a new minimally invasive Achilles reconstruction technique and to assess the perioperative morbidity, medium- to long-term outcomes, and functional results.

METHODS

Our series was comprised 14 patients (11 men and 3 women), with a mean age of 45.6 years at surgery. Each patient had a chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (range, 2-10). The mean total follow-up was 30.1 months (range, 12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach assisted by endoscopy. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion.

RESULTS

The length of the defect ranged from 3 to 8 cm (mean, 5.1), while the length of the turndown flap ranged from 8 to 13 cm (mean, 10.1). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at last follow-up. The mean ATRS score improved from 49.4 preoperatively to 91.4 points at last follow-up. None of the patients developed a wound complication. No patient had a rerupture or sural nerve damage.

CONCLUSION

All patients in our study had a favorable outcome with no complications. We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A Case of Heel Cord Pain After Repair of Acute Achilles Tendon Rupture: Treated by Endoscopic Adhesiolysis of the Achilles Tendon

The causes of heel cord pain after repair of acute rupture of the Achilles tendon are unclear. The proposed etiologies include nonabsorbable suture granuloma formation, alteration of the pain receptors threshold in the tendon, and distension of the paratenon by the hypertrophied tendon, underlying tendinopathy, postrepair neovascularization, and peritendinous fibrous adhesion. We present an endoscopic technique of adhesiolysis of the Achilles tendon to deal with the various possible causes of postrepair heel cord pain.

LEVELS OF EVIDENCE

Therapeutic, Level 4: Case report.

Early Ankle Mobilization Promotes Healing in a Rabbit Model of Achilles Tendon Rupture

The use of early mobilization of the ankle joint without orthosis in the treatment of Achilles tendon rupture has been advocated as the optimal management. The goal of this study was to compare outcomes in a postoperative rabbit model of Achilles tendon rupture between early mobilization and immobilized animals using a differential proteomics approach. In total, 135 rabbits were randomized into the control group (n=15), the postoperative cast immobilization (PCI) group (n=60), and the early mobilization (EM) group (n=60). A rupture of the Achilles tendon was created in each animal model and repaired microsurgically, and tendon samples were removed at 3, 7, 14, and 21 days postoperatively. Proteins were separated using 2-dimensional polyacrylamide gel electrophoresis and identified using peptide mass fingerprinting, tandem mass spectrometry, NCBI database searches, and bioinformatics analyses. A series of differentially expressed proteins were identified between groups, some of which may play an important role in Achilles tendon healing. Notable candidate proteins that were upregulated in the EM group were identified, such as CRMP-2, galactokinase 1, tropomyosin-4, and transthyretin. The healing of ruptured Achilles tendons appears to be affected at the level of protein expression with the use of early mobilization. The classic postoperative treatment of Achilles tendon rupture with an orthosis ignored the self-protecting instinct of humans. With a novel operative technique, the repaired tendon can persist the load that comes from traction in knee and ankle joint functional movement. In addition, kinesitherapy provided an excellent experimental outcome via a mechanobiological mechanism.

Nanoparticles for Tendon Healing and Regeneration: Literature Review

Tendon injuries are commonly met in the emergency department. Unfortunately, tendon tissue has limited regeneration potential and usually the consequent formation of scar tissue causes inferior mechanical properties. Nanoparticles could be used in different way to improve tendon healing and regeneration, ranging from scaffolds manufacturing (increasing the strength and endurance or anti-adhesions, anti-microbial, and anti-inflammatory properties) to gene therapy. This paper aims to summarize the most relevant studies showing the potential application of nanoparticles for tendon tissue regeneration.

Minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization

Background

Plantaris tendon, peronus brevis tendon and flexor hallucis longus tendon augmentation, commonly used in Achilles tendon rupture, often lead to weakening of injured foot and they require the immobilization after the surgery. It is essential to develop the technique, which gives no such limitation and allows for immediate functional improvement.

Methods

We present our method of minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization.

Results

Posterolateral and posteromedial portals were made approximately 3 cm above the posterosuperior part of the calcaneus to clean the area of the Achilles tendon endoscopically. Then the hamstrings are harvested and prepared for the “Endobutton” system. A midline incision of the skin is performed approximately 1 cm above the posterosuperior part of the calcaneus to approach to the posterosuperior part of the calcaneus. Then under fluoroscopy the calcaneus was drilled through using K-wire. The distal end of the graft equipped with an Endobutton loop was entered into the drilled tunnel in the calcaneus. Later, 8 consecutive skin incisions are performed. Proximal ends of the graft were brought out through the native Achilles tendon reaching medial and lateral skin incisions. The final step was to transfer and tie the graft ends through the most proximal skin incision.

Conclusions

This minimally invasive, endoscopic technique allows reconstruction of the Achilles tendon using semitendinosus and gracilis tendons with Endobutton stabilization and can be used in so-called “difficult”, resistant cases as a “salvage procedure”.

An Alternative Bundle-to-Bundle Suturing Technique for Repairing Fresh Achilles Tendon Rupture

The main concern about conventional Achilles tendon repair surgical techniques is how to maintain the initial strength of the ruptured Achilles tendon through complicated suturing methods. The primary surgical problem lies in the properties of the soft tissue; the deterioration of the Achilles tendon, especially in its elasticity; and the surface lubricity of the local tissues. In the present study, we describe an innovative bundle-to-bundle suturing method that addresses these potential problems.

Complications of Tendon Surgery in the Foot and Ankle

This article discusses four subsets of patients that have an increased risk of complications from tendon surgery in the foot and ankle: smokers, diabetics, and patients with peroneal or Achilles tendon pathology. Very little has been published on the complications of other tendon surgeries in the foot and ankle other than Achilles tendon repair. Data can be extrapolated from the general orthopedic literature and animal studies to help guide therapy and treatment options. The foot and ankle surgeon must take into account the entirety of the history and physical examination to develop a treatment plan that optimizes each patient's chance for a complication-free recovery.

Chronic Achilles Tendon Rupture Reconstructed With Achilles Tendon Allograft and Xenograft Combination

More than 20% of acute Achilles tendon injuries are misdiagnosed, leading to chronic or neglected ruptures. Some controversy exists regarding how to best manage an acute Achilles tendon rupture. However, a general consensus has been reached that chronic rupture with ≥3 cm of separation is associated with functional morbidity and, therefore, should be managed operatively. It has been demonstrated that the functional outcomes of surgically treated Achilles ruptures are superior to the nonoperative outcomes in a chronic setting. In the present report, we reviewed 4 patients with chronic Achilles tendon ruptures that were successfully treated with an Achilles tendon interposition allograft and simultaneous augmentation with a xenograft. The median duration of rupture was 11 (range 8 to 16) weeks, the median gap between the proximal and distal segments of the tendon was 4.75 (range 3.5 to 6) cm, and the patients were able to return pain-free to all preinjury activities at a median of 14.5 (range 13.8 to 15.5) weeks, without the need for tendon transfer, lengthening, or additional intervention. The median duration of follow up was 37.25 (range 15.25 to 51.5) months, at which point the mean Foot and Ankle Outcomes Instrument core scale score was 97 ± 1 (mean normative score 53 ± 1), and the Foot and Ankle Outcomes Instrument shoe comfort core scale score was 100 ± 0 (mean normative score 59 ± 0). The combined Achilles allograft plus xenograft augmentation technique appears to be a reasonable option for the surgical treatment of chronic Achilles tendon rupture.

Active Achilles tendon kinesitherapy accelerates Achilles tendon repair by promoting neurite regeneration

Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7–21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy.

Trends in the Management of Achilles Tendon Ruptures in the United States Medicare Population, 2005-2011

Background:

Achilles tendon ruptures are one of the most commonly treated injuries by orthopaedic surgeons and general practitioners. Achilles tendon ruptures have classically been thought to affect the middle-aged “weekend warrior” participating in basketball, volleyball, soccer, or any other ground sport that requires speed and agility; however, with a more active elderly population, these tears are becoming more common in older patients.

Purpose:

To report trends in nonoperative and operative treatment of Achilles tendon tears in the United States from 2005 to 2011 in patients registered with a large Medicare database.

Study Design:

Descriptive epidemiological study.

Methods:

Patients who underwent nonoperative and operative treatment of Achilles tendon ruptures by either primary repair or primary repair with graft (International Classification of Diseases 9 [ICD-9] diagnosis code 727.67, Current Procedural Terminology [CPT] codes 27650 and 27652) for the years 2005 to 2011 were identified using the PearlDiver Medicare Database. Demographic and utilization data available within the database were extracted for patients who underwent nonoperative as well as operative treatment for Achilles tendon ruptures. Statistical analysis involved Student t tests, chi-square tests, and linear regression analyses, with statistical significance set at P < .05.

Results:

From 2005 to 2011, there were a total of 14,127 Achilles tendon ruptures. Of these, 9814 were managed nonoperatively, 3531 were treated with primary repair, and 782 were treated with primary repair with graft. The incidence of Achilles tendon increased from 0.67 per 10,000 in 2005 to 1.08 per 10,000 in 2011 (P < .01). There was no significant difference in the number of Achilles ruptures between males (6636) and females (7582) (P > .05). There was an increase in the overall number of Achilles tendon ruptures over time (1689 in 2005 compared with 2788 in 2011; P < .001) but no difference in the percentage of Achilles ruptures treated operatively (P > .05). Older patients were more likely to be treated nonoperatively (P < .05). No differences in operative versus nonoperative treatment were seen between yearly quarter (P > .05), sex (P > .05), or region (P > .05).

Conclusion:

The incidence of Achilles tendon ruptures is increasing with time, but the trend in operative and nonoperative treatment has not changed between 2005 and 2011. Older patients, especially those older than 85 years, are more likely to be treated nonoperatively. No differences in treatment patterns were seen based on sex, region, or yearly quarter.

Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials

BACKGROUND

Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate.

METHODS

A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion.

RESULTS

Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).

CONCLUSIONS

The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients.

The pathogenesis of tendon microdamage in athletes: the horse as a natural model for basic cellular research

The equine superficial digital flexor tendon (SDFT) is a frequently injured structure that is functionally and clinically equivalent to the human Achilles tendon (AT). Both act as critical energy-storage systems during high-speed locomotion and can accumulate exercise- and age-related microdamage that predisposes to rupture during normal activity. Significant advances in understanding of the biology and pathology of exercise-induced tendon injury have occurred through comparative studies of equine digital tendons with varying functions and injury susceptibilities. Due to the limitations of in-vivo work, determination of the mechanisms by which tendon cells contribute to and/or actively participate in the pathogenesis of microdamage requires detailed cell culture modelling. The phenotypes induced must ultimately be mapped back to the tendon tissue environment. The biology of tendon cells and their matrix, and the pathological changes occurring in the context of early injury in both horses and people are reviewed, with a particular focus on the use of various tendon cell and tissue culture systems to model these events.