Acute Achilles tendon rupture: Mini-incision repair with double-Tsuge loop suture vs. open repair with modified Kessler suture

Paratenon preserving repair of the midsubstance acute Achilles tendon rupture: a systematic review and meta-analysis with best- and worst-case analyses for rerupture rates

INTRODUCTION

Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR.

MATERIALS AND METHODS

A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I2 < 25% (low heterogeneity), and random effects models were employed if I2 ≥ 25% (moderate to high heterogeneity).

RESULTS

The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%.

CONCLUSIONS

Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR.

The percutaneous oval forceps suture-guiding method with anchor nails for Achilles tendon repair

BACKGROUND

Acute Achilles tendon rupture (AATR) is a common injury of the foot and ankle. So far, the optimal management of AATR remains controversial. The target of the present retrospective study was to describe a new operative technique for percutaneous repair of AATR and evaluate efficacy of the technique.

METHODS

In the present study, 32 patients were enrolled with AATR treated with the percutaneous oval forceps suture-guiding method with anchor nails from Jan 2014 to Jan 2017. The operation duration and length of incision were collected. The functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, Achilles tendon total rupture score (ATRS), range of motion (ROM) of the ankle and plantar flexion strength ratio at the last follow-up. The postoperative sports activity level and complications were also recorded.

RESULTS

The mean operation duration and length of incision were 24.5 min and 2.0 cm. Whilst patient reported outcome questionnaires like AOFAS and ATRS showed good results, ROM of the ankle was quite low with only 16.5 degrees. Plantar flexion strength ratio was lower post surgery, as well. As for the postoperative sports activity level: 26/32 cases (81.3%) returned to former sports activity level; 4/32 cases (12.5%) showed a decline in sports activity level; 2/32 cases (6.2%) gave up on sports. The overall complication rate was 6.2%, one sural nerve damage and one fusiform thickening were found in the study.

CONCLUSION

The percutaneous oval forceps suture-guiding method with anchor nails is a new considerable surgery method with adequate healing rates and an alternative to existing surgical procedures.

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.

Comparison of the Effects of Pulsed Electromagnetic Field and Extracorporeal Shockwave Therapy in a Rabbit Model of Experimentally Induced Achilles Tendon Injury

Achilles tendon injuries are a common cause of complications including adhesions and tendon degeneration. As a result of these complications, the biomechanical properties are lost. Extracorporeal shockwave therapy (ESWT) and pulsed electromagnetic field (PEMF) recover the injured tendon structure; however, detailed studies of changes in tendon biomechanical properties are limited. We hypothesized that PEMF application would improve Achilles tendon biomechanical properties similar to ESWT. The curative effects of a PEMF 4-week application (15 Hz, 1 mT, 260 µs, 1 h/day) and ESWT (3 doses/28 days, 1st dose: 0.12 mJ/mm2 , 15 Hz, 300 impulses; 2nd dose: 0.14 mJ/mm2 , 15 Hz, 500 impulses; 3rd dose: 0.14 mJ/mm2 , 15 Hz, 500 impulses) on rabbits with Achilles tendon injury were investigated in terms of histopathological and biomechanical properties. The clinical feasibility of PEMF application was evaluated by comparing the results of both methods. Fifty New Zealand female rabbits were divided into two groups to be used in either biomechanical or immunohistochemical studies. Each of the two groups was further divided into five groups: C (Control), SH (Sham), TI (tendon injury), TI + ESWT, and TI + PEMF. Biomechanical evaluations revealed that maximum load, toughness, and maximum stress averages of the TI + PEMF group significantly increased (P < 0.05). When immunohistochemical images of the TI + PEMF group were compared with those of the TI group, the amount of fibrous tissue was less, the homogeneity of collagen fibers recovered, and collagen organization was more uniform. We conclude that both ESWT and PEMF are equally efficient for Achilles tendon recovery. PEMF application is effective and can be used in the clinic as a painless alternative treatment method. © 2020 Bioelectromagnetics Society.

Biomechanical comparison of Bunnell, modified Kessler, and Tsuge tendon repair techniques using two suture types

OBJECTIVE

The aim of this study was to compare the biomechanical properties of modified Kessler, Bunnell and Tsuge techniques in sheep Achilles tendon tear repaired using polyester and polydioxanone sutures which are also compared.

METHODS

Sixty sheep Achilles tendons were cut transversely as a substitute for rupture and repaired using modified Kessler, Bunnell and Tsuge techniques with No. 2 braided polyester and monofilament polydioxanone sutures. Specimens were loaded to failure. Four biomechanical parameters - ultimate strength (US), strength to 2 mm gap (S2G), strength to 5 mm gap (S5G) and Young's modulus (YM) - were recorded for statistical analysis.

RESULTS

The Tsuge-Polyester group demonstrated the highest results regarding S2G (21.24±4.75 N) (p=.002) and S5G (38.91±7.45 N) (p=.002). According to YM, the Bunnell-Polyester group was the most superior (1929.9±512.28 kilopascal) (p=.009). In the repairs with the polydioxanone suture, Bunnell technique achieved the best purchase with regard to S2G (18.14±6.86 N) (p=.006) and S5G (35.69±13.49 N) (p=.015). The difference between the three repair techniques with the polydioxanone suture was statistically insignificant regarding US (p=.252) and YM (p=.338). Concerning the repairs with the polyester suture, the repair techniques demonstrated no statistically significant difference in terms of US (p=.195), S2G (p=.667), S5G (p=.689) and YM (p=.195). Regarding the mean S2G and S5G values, the polyester suture was significantly superior to the polydioxanone suture in modified Kessler repairs (S2G: p<.001, S5G: p=.001) and Tsuge repairs (S2G: p<.001, S5G: p=.009). The polyester suture was also significantly superior to the polydioxanone suture in the modified Kessler repairs with respect to YM (p=.003).

CONCLUSION

This study supports the opinion that Tsuge technique is a promising procedure in Achilles tendon repair (ATR). For Tsuge and modified Kessler repairs, braided polyester suture use appears more advantageous compared to monofilament polydioxanone suture use in biomechanical terms.

Strength Measurement After Achilles Tendon Repair

The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.

Increasing age in Achilles rupture patients over time

BACKGROUND

The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time.

METHODS

Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies.

RESULTS

The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI.

CONCLUSION

Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years.

LEVEL OF EVIDENCE

Level III; Retrospective cohort study.