Augmented Repair of Acute Achilles Tendon Rupture Using an Allograft Tendon Weaving Technique

One Step Double Augmentation with Human Dermis Allograft and Homologous PRP in Misdiagnosed and or Chronic Achilles Tendon Ruptures

OBJECTIVE

Misdiagnosed/chronic Achilles tendon injuries are rare and disabling for patients. The surgical treatment of these rare injuries aims to ensure the tendon heals mechanically and biologically. This is the prerequisite for a good clinical and functional outcome and reduces recurrences. The main aim of the study is to present a surgical technique that has proven to be original, reproducible, and capable of guaranteeing solid tendon repair and optimal tissue regeneration.

METHODS

We treated five patients, four males and one female, with the one-step double augmentation technique. All patients of this study complained of pain, but above all severe functional limitation that Achilles tendon injury had been causing for more than a month. In this study, we widely described the surgical technique, original and not found in the literature, which provides a biological graft (allograft of decellularized dermis) and homologous, thrombin-activated, platelet-rich plasma (H-PRP) in a single step. Surgical approach, always used by the first author, respected predefined steps: careful dissection and preparation of the peritendinous tissues from suture to the end of the procedure, tenorrhaphy, and augmentation with allopatch to obtain a mechanically effective repair to avoid recurrences, and finally "biological" augmentation with a unit of homologous, thrombin activated, PRP. We offered to all patients a regenerative rehabilitation program post-operatively.

RESULTS

All patients were evaluated clinically (functional clinical tests and questionnaires) and instrumentally (elastic-sonography and perfusion MRI). The obtained results have been evaluated at a minimum follow-up of 18 months and a maximum of 24 months. In all patients pain was resolved, and district function and kinetic chains improved with resumption of daily activities, work, and sports.

CONCLUSION

The present study confirmed the regenerative potential of decellularized dermis allograft and PRP (homologous and thrombin-activated). The same approach can also be exploited in cases of severe tendon destructuring and limited "intrinsic" regenerative potential at any age. The proposed one-step surgical technique of a double augmentation therefore appears useful, safe, reproducible, and applicable in all chronic tendon lesions with low regenerative potential.

[Application of posterior median longitudinal W-shaped incision combined with layer-by-layer combing suture in acute closed Achilles tendon rupture]

OBJECTIVE

To explore the effectiveness of posterior median longitudinal W-shaped incision combined with layer-by-layer combing suture in the treatment of acute closed Achilles tendon rupture.

METHODS

The clinical data of 32 patients with acute closed Achilles tendon rupture who met the selection criteria between August 2015 and February 2019 were retrospectively analyzed. There were 25 males and 7 females, with an average age of 33 years (range, 21-48 years). All of them were closed rupture of Achilles tendon caused by sports injury. Physical examination on admission: the rupture space of Achilles tendon was palpable; Thompson sign was positive; the rupture of Achilles tendon was confirmed by MRI and ultrasonography before operation, the distance between the broken end and the insertion point of Achilles tendon was 2-8 cm, with an average of 3.5 cm. The average time from injury to operation was 2.7 days (range, 1-10 days). During the operation, the posterior median longitudinal W-shaped incision of Achilles tendon was used to expose the broken end of Achilles tendon, and the deep and shallow double Kessler end-to-end suture+layer-by-layer combing suture were used to suture the Achilles tendon, and the skin incision was sutured by "V-Y"advancement. The postoperative complications were observed; the healing of Achilles tendon was observed by ultrasonography; at last follow-up, Arner Lindholm criteria was used to evaluate ankle function.

RESULTS

The 32 patients were followed up 8-24 months, with an average of 12 months. The incision healed by first intention, without the complications of skin necrosis, nonunion, delayed healing, and infection, scar hyperplasia or ulcer, and symptom of peroneal nerve injury. No Achilles tendon rupture and deep infection occurred during the follow-up period. The ultrasonography examination showed that the Achilles tendon was healing. At last follow-up, according to Amer Lindholm evaluation standard, the results of ankle function was excellent in 26 cases and good in 6 cases.

CONCLUSION

The treatment of acute closed Achilles tendon rupture with a posterior median longitudinal W-shaped incision combined with deep and shallow double Kessler end-to-end suture+layer-by-layer combing suture is effective, which can fully exposed the incision, the quality of Achilles tendon anastomosis is reliable, and it can effectively avoid wound complications and iatrogenic injury of gastrocnemius nerve.

Functional reconstruction of severe hand injuries using allogeneic tendons: a retrospective study

Objective

To evaluate the effectiveness and safety of allogeneic tendons for functional reconstruction of severe hand injuries.

Methods

From August 2007 to July 2014, we performed functional reconstruction with tendon allografts for severe hand injuries affecting two or more tendons. At the final follow-up, we assessed total active motion (TAM); pincer pinch strength; grip strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; degree of satisfaction; and adhesion. We measured the white blood cell count, C-reactive protein concentration, erythrocyte sedimentation rate, total T-cell count, and CD4⁺T/CD8⁺T ratio to evaluate the immune response and check for infection.

Results

Ten patients received 26 allogeneic tendons to reconstruct hand function. The average follow-up period was 50.0 months (range, 24–82 months). The TAM was 126.4° (12°–253°), pincer pinch strength was 0.83 kg (0–4.5 kg), and grip strength was 13.69 kg (4–41.5 kg). The DASH score was 14.25 (3.3–30.8), and seven and three patients were satisfied and partially satisfied, respectively. One patient developed tendon adhesion. All immune and infectious parameters were within the reference range.

Conclusion

Functional reconstruction using allogeneic tendons for severe hand injuries with multiple tendon defects was effective and safe; however, more research is needed.

Peroneus Brevis flap in Achilles tendon reconstruction. Clinical, radiological and functional analysis

BACKGROUND

We would like to describe our experience with Peroneus Brevis flap in complicated Achilles tendon re-ruptures with fringed stumps.

METHODS

Eight patients with monolateral re-rupture of Achilles tendon were selected as eligible for surgical repair with Peroneus Brevis flap. Patients' outcome was evaluated clinically (ATRS and ROM), functionally (Gait analysis) and MRI was performed before and after surgery.

RESULTS

Effective coverage of tissue defect was reached in all patients. Functional assessment evaluation results were registered in a follow-up time that ranged from 12 to 18 months. ATRS and ROM tests' results showed good functional recovery without functional limitations or subjective reports pain. Post-operative MRI showed no signs of inflammation or tissue gaps. Gait analysis showed a partial reduction of performance in the affected side that did not affect patients' quality of life.

CONCLUSIONS

In the presence of fringed stumps in Achilles tendon re-rupture, tendon flaps have the benefits of autologous tissues transfers and present less risks of failure than free flaps. Among them, Peroneus Brevis flap is easy to perform and leads to donor site's low morbidity. Our preliminary experience provides support for this technique to be potentially validated in larger more controlled trial.

Electrospun thymosin Beta-4 loaded PLGA/PLA nanofiber/ microfiber hybrid yarns for tendon tissue engineering application

Microfiber yarns (MY) have been widely employed to construct tendon tissue grafts. However, suboptimal ultrastructure and inappropriate environments for cell interactions limit their clinical application. Herein, we designed a modified electrospinning device to coat poly(lactic-co-glycolic acid) PLGA nanofibers onto polylactic acid (PLA) MY to generate PLGA/PLA hybrid yarns (HY), which had a well-aligned nanofibrous structure, resembling the ultrastructure of native tendon tissues and showed enhanced failure load compared to PLA MY. PLGA/PLA HY significantly improved the growth, proliferation, and tendon-specific gene expressions of human adipose derived mesenchymal stem cells (HADMSC) compared to PLA MY. Moreover, thymosin beta-4 (Tβ4) loaded PLGA/PLA HY presented a sustained drug release manner for 28 days and showed an additive effect on promoting HADMSC migration, proliferation, and tenogenic differentiation. Collectively, the combination of Tβ4 with the nano-topography of PLGA/PLA HY might be an efficient strategy to promote tenogenesis of adult stem cells for tendon tissue engineering.

Clinical applications of allografts in foot and ankle surgery

PURPOSE

The purpose of this review is to systematically analyse current literature on the use of allografts in the surgical treatment of foot and ankle disorders in adult patients. Based on this study, we propose evidence-based recommendations.

METHODS

The database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: performed on patients over 18 years old; subject to surgical treatment of foot and ankle disorders; with report on the outcome of the use of allografts; with a report and assessment of pain and function, or equivalent; minimum follow-up of 1 year was required. Two reviewers independently screened and selected studies for full-text analysis from title and abstract. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n = 16), chronic ankle instability (n = 15), ankle arthritis (n = 14), osteochondral lesions of the talus (n = 12), Achilles tendon defects (n = 11), other tendon defects (n = 9), fusions (n = 9), fractures (n = 8), hallux rigidus (n = 3) and other indications (n = 10).

RESULTS

Most studies displayed evidence level of IV (n = 57) and V (n = 39). There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n = 99; 92.5%). Overall complication rate was 17% (n = 202).

CONCLUSIONS

Fair evidence (Grade B) was found in favour of the use of allografts in lateral ankle ligament reconstruction or treatment of intra-articular calcaneal fracture. Fair evidence (Grade B) was found against the use of allogeneic MSCs in tibiotalar fusions.

LEVEL OF EVIDENCE

V.

Achilles Tendon Augmented Repair Using Human Acellular Dermal Matrix: A Case Series

Achilles tendon ruptures are common in the general population, especially among members of the older demographic occasionally active in sports. Operative treatments provide a lower incidence of rerupture than do nonoperative treatments, although surgical complications remain a concern. The use of a human acellular dermal matrix to augment Achilles tendon repair might reduce the incidence of complications. In the present case series, we describe the outcomes of 9 patients who underwent Achilles tendon repair with acellular dermal matrix augmentation. Functional outcomes were evaluated using the Foot Function Index-Revised long form, and the clinical results were recorded. After a mean average follow-up period of 14.4 (range 12.0 to 20.0) months, the mean Foot Function Index-Revised long form score was 33.0% ± 4.2%. No cases of rerupture or complications that required additional treatment occurred during the observation period. The outcomes we have presented support further evaluation beyond this case series for using a human acellular dermal matrix to augment Achilles tendon repairs.

A Percutaneous Knotless Technique for Acute Achilles Tendon Ruptures

Achilles tendon ruptures are a common tendon injury, usually occurring in middle-aged men during recreational sporting activities. Both nonoperative and operative management are employed to treat these injuries. Several operative treatments are described in the literature, including percutaneous Achilles repair, mini-open repair, and open repair. Open Achilles repair is associated with higher rates of impaired wound healing and infection, whereas minimally invasive techniques have been reported to have an increased risk of iatrogenic sural nerve injury. More recently, low complication rates, improved cosmetic appearance, reduced operating times, and improved clinical outcomes have been reported for the percutaneous Achilles repair technique. In this Technical Note, we present our preferred technique using the Percutaneous Achilles Repair System (Arthrex, Naples, FL), which has been reported to have minimal wound and nerve complications, and early return to activity.

Development and reliability of the Achilles Tendon Length Measure and comparison with the Achilles Tendon Resting Angle on patients with an Achilles tendon rupture

BACKGROUND

There is a need for a valid, reliable, and easily applicable clinical measure of the length of the Achilles tendon (AT) after rupture. This study examines the reliability of a new ruler based measurement, the Achilles Tendon Length Measure (ATLM) in comparison with the goniometer-based Achilles Tendon Resting Angle (ATRA).

METHODS

Measurements were performed by two independent physiotherapists eight weeks after AT rupture on 28 patients treated non-operatively.

RESULTS

The mean (SD) injured ATLM was 56.5 (2.3)cm, ICC_2.1 0.91(CI [0.72-0.97]), SEM 0.7cm (SEM% 1.2), MDC 1.9cm (MDC% 3.4). Corresponding data for the injured ATRA was mean 64.4° (3.9°), ICC_2.1 0.84 (CI [0.68-0-92]), SEM 1.5° (SEM% 2.4), MDC 4.3° (MDC% 6.6).

CONCLUSION

Both ATLM and ATRA showed excellent inter-rater reliability with low measurement error. Both measurements seem easy to use in clinical practice and potentially providing an indirect measure of the length of the AT after rupture.

Effect of scaffold morphology and cell co-culture on tenogenic differentiation of HADMSC on centrifugal melt electrospun poly (L‑lactic acid) fibrous meshes

Engineered tendon grafts offer a promising alternative for grafting during the reconstruction of complex tendon tears. The tissue-engineered tendon substitutes have the advantage of increased biosafety and the option to customize their biochemical and biophysical properties to promote tendon regeneration. In this study, we developed a novel centrifugal melt electrospinning (CME) technique, with the goal of optimizing the fabrication parameters to generate fibrous scaffolds for tendon tissue engineering. The effects of CME processing parameters, including rotational speed, voltage, and temperature, on fiber properties (i.e. orientation, mean diameter, and productivity) were systematically investigated. By using this solvent-free and environmentally friendly method, we fabricated both random and aligned poly (L-lactic acid) (PLLA) fibrous scaffolds with controllable mesh thickness. We also investigated and compared their morphology, surface hydrophilicity, and mechanical properties. We seeded human adipose derived mesenchymal stem cells (HADMSC) on various PLLA fibrous scaffolds and conditioned the constructs in tenogenic differentiation medium for up to 21 days, to investigate the effects of fiber alignment and scaffold thickness on cell behavior. Aligned fibrous scaffolds induced cell elongation and orientation through a contact guidance phenomenon and promoted HADMSC proliferation and differentiation towards tenocytes. At the early stage, thinner scaffolds were beneficial for HADMSC proliferation, but the scaffold thickness had no significant effects on cell proliferation for longer-term cell culture. We further co-seeded HADMSC and human umbilical vein endothelial cells (HUVEC) on aligned PLLA fibrous mats and determined how the vascularization affected HADMSC tenogenesis. We found that co-cultured HADMSC-HUVEC expressed more tendon-related markers on the aligned fibrous scaffold. The co-culture systems promoted in vitro HADMSC differentiation towards tenocytes. These aligned fibrous scaffolds fabricated by CME technique could potentially be utilized to repair and regenerate tendon defects and injuries with cell co-culture and controlled vascularization.

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.