Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature

Safety Profile of Synthetic Elastic Degradable Matrix for Soft Tissue Reconstruction in Foot & Ankle Surgery

BACKGROUND

Augmentation of soft tissue repairs has been helpful in protecting surgically repaired tissues as they heal. FlexBand (Artelon, Marietta, Georgia) is a synthetic, degradable, polycaprolactone-based polyurethane urea (PUUR) matrix that has been investigated and used for soft tissue repair in a variety of settings. The purpose of this study was to evaluate the safety profile of a PUUR matrix in a large cohort of patients undergoing soft tissue repairs about the foot and ankle.

METHODS

A retrospective chart review of consecutive patients who underwent surgery using FlexBand to augment a soft tissue repair was performed to evaluate for major and minor complications related to the PUUR matrix. Results. A total of 105 patients with an average >6 months follow-up were included. The most common procedures were spring ligament repair, Achilles tendon repair, and Brostrom. There were 12 complications. Four major complications occurred with only 1 requiring PUUR matrix removal. Patients with wound complications had a higher body mass index (BMI) and rate of smoking.

CONCLUSION

Complication rates involving PUUR matrix in soft tissue foot and ankle reconstruction procedures are low and comparable with historical complication rates. The PUUR matrix is safe for use in a variety of soft tissue procedures about the foot and ankle.Level of Evidence: Level 4, Retrospective case-series.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Outcomes of Open Repair Treatment for Acute Versus Chronic Achilles Tendon Ruptures: Long-Term Retrospective Follow-Up of a Minimum 10 Years-A Pilot Study

The aim of the present study was to compare repaired Achilles tendon (AT) remodelling, whether its function was restored and what effects the surgery had on our patients' gait cycle in a long-term follow-up study. The study population comprised 30 human subjects treated acutely and chronically for AT ruptures, using the same surgical technique in all cases. The study group was divided into two subgroups regarding the age of their AT injury, i.e., how much time elapsed between the injury and when a correct diagnosis was made and when adequate treatment was applied. Following these criteria, persons presenting at less than 4 weeks postinjury were classified as acute rupture (AR) patients and those presenting at more than 4 weeks after injury were grouped as chronic rupture (CR) patients. Both patient groups were operated on using a surgical method favoured at least a decade ago, i.e., open repair through a posteromedial approach. The AT was augmented with a plantaris longus tendon autograft, followed by suturing using the pull-out suture technique. The results were measured using clinical, ultrasonographic (US) and pedobarographic methods. Our ultrasonographic and pedobarographic findings revealed differences between both patient groups, thus indicating that delayed surgery had negative impacts on treatment success, however, with good long-term functional score outcomes in both patient groups. Nevertheless, delayed treatment of AT ruptures did not leave individual gait phases unaffected, as it also affected the plantar surface and balance performance of the affected limb. As per the results, the Achilles tendon manifested decreased capacity following delayed treatment; however, its long-term functional outcomes were favourable, irrespective of whether it was for acute or chronic patients.

Spacer exchange in persistent periprosthetic joint infection: microbiological evaluation and survivorship analysis

PURPOSE

The purposes of this study were to determine demographics and characteristics of patients who underwent spacer exchange for persistent infection in the setting of two-stage arthroplasty for periprosthetic joint infection, to describe the microbiology of pathogens involved, to analyze survivorship free from infection in these patients.

METHODS

The institutional prospectively collected database was reviewed to enroll patients with minimum 2 years follow-up. Patients who underwent two-stage procedure for septic arthritis were excluded, as were patients who had spacer fracture or dislocation.

RESULTS

A total of 34 patients (41 procedures) were included. Mean age was 65.0 ± 12.8 years. Mean follow-up was 53.4 ± 24.8 months. Mean number of previous procedures was 3.6 ± 1.2. A total of 27 (79.4%) patients underwent final reimplantation. The most frequently isolated pathogen in spacer exchange was Staphylococcus epidermidis (10 cases, 28.6%). Polymicrobial cultures were obtained from 9 (25.71%) patients, 10 (28.6%) presented culture-negative infections. A total of 11 (32.4%) resistant pathogens were isolated, and 16 (47.0%) difficult to treat pathogens were detected. Eradication rate was 78.8%. Overall survivorship of implants after final reimplantation was 72.8% at 51.8 months.

CONCLUSION

Surgeons should be aware that subjects necessitating spacer exchange often present multiple comorbidities, previous staged revision failures, soft-tissue impairment and difficult to treat infection. In these patients, spacer exchange provides good clinical results and infection eradication, preventing arthrodesis or amputation.

A New Technique of Achilles Tendon Rupture Repaired by Double Transverse Mini-incision to Avoid Sural Nerve Injury: A Consecutive Retrospective Study

OBJECTIVE

Percutaneous suture is a classic technique used in Achilles tendon repair. However, the complication rates surrounding the sural nerve remain relatively high. Modified percutaneous repair technology can effectively avoid these complications; however, the surgical procedure is complicated. Hence, the present study was conducted to describe a redesigned repair technique for the Achilles tendon able to avoid sural nerve injury and reduce the complexity of the procedure.

METHODS

Data of patients with acute primary Achilles tendon rupture at our hospital from January 2019 to May 2020 were included. Subjects with expectations for surgical scarring underwent a minimally invasive-combined percutaneous puncture technique. The surgical time, requirement for conversion to other technologies, and length of postoperative hospitalization were investigated to assess efficacy. The American Orthopedic Foot & Ankle Society (AOFAS) score and the Arner-Lindholm scale (A-L scale) were used to assess postoperative clinical outcomes (> 24 months). During the 2-year follow-up, MRI was performed to observe the healing of the Achilles tendon. In addition, subjective satisfaction with surgical scar healing was recorded.

RESULTS

Twenty consecutive subjects with an average follow-up of 28.3 ± 4.5 months (range, 24-41) met the inclusion criteria. None of the 20 enrolled patients required a converted surgical approach. The mean surgical time was 26.9 ± 6.47 min (range, 20-44). None of the patients experienced dysesthesia or anesthesia around the sural nerve. No signs of postoperative infections were observed. MRI data showed that the wounds of the Achilles tendon healed completely in all the subjects. The AOFAS score increased from 55.6 ± 11.07 (range, 28-71) preoperatively to 97.8 ± 3.34 (range, 87-100) at the last follow-up. The A-L scale showed that 90% of the subjects (n = 18) presented as excellent and 10% of the subjects (n = 2) presented as good, with an excellent/good rate of 100%. Moreover, subjects' satisfaction for surgical scars was 9.1 ± 0.78 (upper limit, 10).

CONCLUSIONS

The results indicate that this technique can achieve good postoperative function, a small surgical incision, and high scar satisfaction. In addition, this technique should be widely used in suturing Achilles tendon ruptures.

Adverse Events Following Minimally Invasive Achilles Tendon Repair

BACKGROUND

The rate of wound complications following traditional open Achilles tendon repair is reported at 7.6%. The purpose of this study is to characterize the rate of wound and other early complications following a specific minimally invasive Achilles tendon repair technique, and to identify any factors associated with increased risk.

METHODS

The postoperative courses of 99 patients who underwent minimally invasive Achilles tendon repair by 2 surgeons at separate academic medical centers were retrospectively reviewed. Mean follow-up was 8.1 months (range 3.0-24.6 months). Repair technique was similar in all cases with the exception that 71 procedures used a longitudinal incision and a tourniquet, while 28 procedures used a transverse incision and no tourniquet (surgeon preference). The rates of complications were compared between patients with differing baseline and procedural characteristics.

RESULTS

Of the 99 patients included in the study, 2 (2.0%) developed wound complications. There was no statistical difference in the rate of wound complications between patients in the longitudinal incision/tourniquet group and patients in the transverse incision/no tourniquet group (2.8% vs 0%; P = 1.000). Four patients (4.0%) developed sural neuropraxia. One patient developed deep venous thrombosis. There were no cases of rerupture. At final follow-up, all 99 patients had intact Thompson tests and well-healed wounds.

CONCLUSIONS

The rate of wound complications following minimally invasive Achilles tendon repair is low at 2.0%. Patients should be counseled that although risk for wound complications may be lower with this minimally invasive technique, there are risks for sural neuropraxia and deep suture reaction.

LEVELS OF EVIDENCE

Level III, Retrospective study.

Trends in Orthopaedic Foot and Ankle Publications

Background:

Scientific publication and original articles remain the primary method of sharing scientific findings and advancing the knowledge base of that subject. Despite the value of these publications, little research has surveyed what topics are being published. This study aims to identify and characterize the most common topics in current foot and ankle literature.

Methods:

We reviewed all 1514 published articles in a 5.5-year period (January 2014–June 2019) in 2 foot and ankle–specific journals: Foot & Ankle International (FAI) and Foot and Ankle Surgery (FAS). The articles were sorted into different topic domains to identify the 3 most common categories of publication. The top 3 domains were further characterized by level of evidence (LOE) as well as citations.

Results:

The 3 most published topics in foot and ankle literature were hallux valgus (8.3%), total ankle arthroplasty (TAA) (8.3%), and ankle fracture (6.6%). These 3 subjects accounted for 351 articles (23.2%). Other common topics were patient-reported outcomes (5.0%), osteochondritis dissecans (3.9%), syndesmotic injury (3.8%), ankle instability (3.7%), hallux rigidus (3.0%), and anatomy (2.8%). The average LOE for articles on hallux valgus, TAA, and ankle fracture was 3.27 from FAI, and the average number of annual citations for a given article in both journals was 3.05. Based on our study, there is no correlation between LOE and number of overall citations, but there is a significant, negative linear correlation in ankle fracture data. We also found that articles on TAA had the highest impact factor and that articles from FAI were cited more often than articles from FAS.

Conclusion:

The 3 most published topics in foot and ankle literature comprise only 23.2% of all articles. This finding is indicative of the wide variety of cases performed by orthopaedic foot and ankle surgeons. High-quality data are still needed in all topics.

Level of Evidence:

Level III, retrospective cohort study.

Accelerated Rehabilitation in Non-operative Management of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis

The optimal treatment and rehabilitation strategy for Achilles tendon ruptures is still under debate. There is a paradigm shift toward early mobilization and weightbearing. We examined the treatment effect of accelerated functional rehabilitation in nonoperative management of acute Achilles tendon ruptures. A systematic search of PubMed, EMBASE, and Web of Science databases for articles comparing accelerated versus delayed rehabilitation in the nonoperative management of acute Achilles tendon rupture was performed. Outcomes of interest were Achilles tendon rupture score (ATRS) (standardized patient-reported instrument related to symptoms and physical activity after treatment of an acute Achilles tendon rupture), rerupture rate, strength, range of motion, return to work, and sports. A total of 2001 articles were identified using our search strategy. We included 6 randomized controlled trials of interest. Although the concept of accelerated rehabilitation has gained popularity in recent years, no statistically significant differences could be revealed in any of the outcomes of interest. We performed a meta-analysis on the following outcomes: ATRS (mean difference -0.93 95% confidence interval [CI] -6.01 to 4.14), Rerupture rate (odds ratio [OR] 0.97, 95% CI: 0.46-2.03), Return to sports (OR 1.31, 95% CI 0.76-2.25), Return to work (mean difference 5.24, 95% CI to -12.04 to 22.51). The treatment effect of accelerated rehabilitation in nonoperatively treated patients seems to be small. However, we recommend accelerated rehabilitation for all conservatively treated patients, because it is a safe option and no detrimental effects have been described in the literature. Furthermore, many patients prefer this type of rehabilitation to avoid the practical disadvantages of prolonged immobilization.

Modified mini-incision "internal splinting" versus percutaneous repair technique of acute Achilles tendon rupture: five year retrospective case-controlled study

PURPOSE

Several kinds of minimally invasive surgical techniques are applied to acute Achilles tendon rupture. The risks of sural never injury and re-ruptures are still major issues. The purpose of this study was to compare the middle-term results of two different minimally invasive repair techniques for acute Achille tendon rupture.

METHODS

Twenty-four cases underwent the modified mini-incision "internal splinting" repair technique in group A, and 29 cases underwent a percutaneous repair technique in group B and were evaluated. The intra-operative data, complications, the time of recovery, and the post-operative magnetic resonance imaging were analyzed. At the final follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Thermann score were evaluated.

RESULTS

The mean follow-up time was 59.96 ± 4.16 months (range 48-67). At the final follow-up, the AOFAS score and Thermann score in both groups had similar feedback. No nerve injury, infection, or re-rupture was encountered in group A, except two cases with anchor irritation. One case with sural nerve injury and one with a re-rupture were recorded in group B, respectively. The final MRI showed thicker regeneration of the tendon in both groups.

CONCLUSIONS

The middle-term results indicated the modified mini-incision "internal splinting" technique for acute Achilles tendon rupture is similar to the percutaneous repair technique. A lower risk of sural nerve injury and re-rupture may be advantages.

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.

Mini-Invasive, Ultrasound Guided Repair of the Achilles Tendon Rupture-A Pilot Study

Percutaneous acute Achilles tendon rupture suturing has become a leading treatment option in recent years. A common complication after this mini-invasive procedure is sural nerve injury, which can reduce the patients’ satisfaction and final outcomes. High-resolution ultrasound is a reliable method for localizing the sural nerve, and it can be performed intra-operatively; however, the long-term results are yet unknown. The aim of the study was to retrospectively evaluate the long-term results of percutaneous Achilles tendon repair supported with real-time ultrasound imaging. We conducted 57 percutaneous sutures of acute Achilles tendon rupture between 2005 and 2015; 30 were sutured under sonographic guidance, while 27 were performed without sonographic assistance. The inclusion criteria were acute (less than 7 days) full tendon rupture, treatment with the percutaneous technique, age between 18 and 65 years, and a body mass index (BMI) below 35. The operative procedure was carried out by two surgeons, according to the surgical technique reported by Maffulli et al. In total, 35 patients were available for this retrospective assessment; 20 (16 men and 4 women) were treated with sonographic guidance, while 15 (12 men and 3 women) underwent the procedure without it. The mean follow-up was 8 years (range, 3–13 years). The sural nerve was localized 10 mm to 20 mm (mean, 15.8; SD, 3.02) laterally from the scar of the Achilles tendon tear. There was no significant difference between groups with respect to the FAOQ score (P < 0.05). High-resolution ultrasounds performed intra-operatively can minimize the risk of sural nerve injury during percutaneous Achilles tendon repair.

Management of Achilles Tendon Injuries in the Elite Athlete

The management of Achilles tendon rupture continues to be controversial in the everyday athlete; however, there is strong evidence indicating that surgical intervention is preferred in elite athletes due to the return of greater strength and peak torque. We review the published literature, as well as our operative technique and post-operative protocol in the management of Achilles tendon injuries in elite athletes.

Clinical Outcomes and Cadaveric Biomechanical Analysis of Endoscopic Percutaneous Achilles Tendon Rupture Repair With Absorbable Suture

Background:

Percutaneous repair of acute Achilles tendon rupture (ATR) continues to gain in popularity. The primary aim of the study was to review the outcomes of a patient cohort undergoing a novel technique of endoscopic percutaneous Achilles tendon repair with absorbable suture. A secondary purpose of this study was to evaluate the basic biomechanical properties of the technique.

Methods:

A cohort of 30 patients who underwent percutaneous ATR repair was retrospectively analyzed with Achilles Tendon Rupture Scores (ATRS), complications, and additional outcome measures. For a biomechanical analysis portion of the study, 12 cadaveric specimens were paired and randomized to either novel percutaneous repair or open Kessler repair with absorbable suture. These specimens were subjected to 2 phases of cyclical testing (100 cycles 10-43 N followed by 200 cycles 10-86 N) and ultimate strength testing.

Results:

In the clinical portion of the study we report excellent patient reported outcomes (mean ATRS 94.1), high level of return to sport, and high patient satisfaction. One partial re-rupture was reported but with no major wound or neurologic complications. In the biomechanical portion of the study we found no significant difference in tendon gapping between percutaneous and open repairs in phase 1 of testing. In phase 2, increased gapping occurred between percutaneous (17.8 mm [range 10.7-24.1, SD 6.4]) and open repairs (10.8 mm [range 7.6-14.9, SD 2.7, P = .037]). The ultimate load at failure was not statistically different between the 2 repairs.

Conclusions:

A percutaneous ATR repair technique using endoscopic assistance and absorbable suture demonstrated low complications and good outcomes in a cohort of patients, with high satisfaction, and excellent functional outcomes including high rates of return to sport. Cadaveric biomechanical testing demonstrated excellent survival during testing and minimal increase in gapping compared with open repair technique, representing sufficient strength to withstand forces seen in early rehabilitation. A percutaneous Achilles tendon repair technique with absorbable suture may minimize risks associated with operative repair while still maintaining the benefit of operative repair.

Level of Evidence:

Level IV, retrospective case series.

Outcomes of open "crown" type v. percutaneous Bunnell type repair of acute Achilles tendon ruptures. Randomized control study

BACKGROUND

The optimal treatment of acute Achilles tendon ruptures (AATR) is still under debate. The purpose of this study was to evaluate outcomes of open repair comparing with percutaneous procedure for AATR.

METHODS

100 patients with AATR were randomized in two groups: open "crown" type (group A) and percutaneous Bunnell type repair (group B). 87 patients were available for the mean follow up of 27months RESULTS: No statistically significant difference was observed between groups in ATRS score, leg circumference, single heel rise, Achilles resting angle, time back to work and sports and overall patient satisfaction. Percutaneous technique was much faster. Overall 13 complications occurred in both groups (5 and 8 respectively). No deep infection occurred, no revisions were needed.

CONCLUSIONS

Both techniques showed to be effective and safe when using absorbable suture material with a high patient satisfaction and a low complication rate, but percutaneous repair was significantly faster.

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.