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Bak BM, Seow D, Teo YZE, Hasan MY, Pearce CJ. Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2024; 63:420-429. [PMID: 38296023 DOI: 10.1053/j.jfas.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/19/2023] [Accepted: 12/18/2023] [Indexed: 02/12/2024]
Abstract
Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.
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Affiliation(s)
| | - Dexter Seow
- National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | | | | | - Christopher J Pearce
- National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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2
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Bragg JT, Ruelos VCB, McIntyre JA, Puzzitiello RN, Pagani NR, Menendez ME, Moverman MA, Salzler MJ. Reverse Fragility Index Comparing Rates of Rerupture After Open Achilles Tendon Repair Versus Early Functional Rehabilitation: A Systematic Review of Randomized Controlled Trials. Am J Sports Med 2024; 52:1116-1121. [PMID: 37306060 DOI: 10.1177/03635465231178831] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Despite similar published rates of rerupture among patients treated with early functional rehabilitation and open repair for acute Achilles tendon rupture, uncertainty still exists regarding the optimal treatment modality. The reverse fragility index (RFI) is a statistical tool that provides an objective measure of the study's neutrality by determining the number of events that need to change for a nonsignificant result to be significant. PURPOSE The purpose was to utilize the RFI to appraise the strength of neutrality of randomized controlled trials (RCTs) comparing the rerupture rates of acute Achilles tendon ruptures treated with open repair versus early functional rehabilitation. STUDY DESIGN Systematic review; Level of evidence, 1. METHODS A systematic review was performed including all RCTs comparing the rerupture rates after operative repair and early functional rehabilitation for acute Achilles tendon ruptures. Studies were included that explicitly used early functional rehabilitation, defined as weightbearing and exercise-based interventions initiated within 2 weeks, as compared with open repair and reported a nonsignificant difference in rerupture rates. The RFI, with rerupture as the primary outcome, was calculated for each study (significance threshold, P < .05). The RFI quantifies a study's strength of neutrality and is defined as the minimum number of event reversals necessary to change a nonsignificant result to statistically significant. RESULTS Nine RCTs were included, with 713 patients and 46 reruptures. The median (interquartile range) rerupture rate was 7.69% (6.38%-9.64%) overall, 4.00% (2.33%-7.14%) in the operative group, and 10.00% (5.26%-12.20%) in the nonoperative group. The median RFI was 3, indicating that an outcome reversal of 3 patients was necessary to change the results from nonsignificant to statistically significant. The median number of patients lost to follow-up was 6 (3-7). Of 9 studies, 7 (77.8%) had a loss to follow-up greater than or equal to its RFI. CONCLUSION The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients.
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Affiliation(s)
- Jack T Bragg
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - J Alex McIntyre
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Nicholas R Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mariano E Menendez
- Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, Oregon, USA
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Matthew J Salzler
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, USA
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Perry AK, Knapik DM, Maheshwer B, Polce EM, Hodakowski AJ, Jackson G, Gursoy S, Chahla J. Lateral meniscus posterior root repair in the setting of anterior cruciate ligament reconstruction restores joint mechanics to the intact state and improves clinical function: a systematic review of biomechanical and clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2023; 31:4474-4484. [PMID: 37516986 DOI: 10.1007/s00167-023-07461-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 05/17/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To perform a systematic review of biomechanical and clinical outcomes following lateral meniscus posterior root (LMPR) repair with concomitant anterior cruciate ligament reconstruction (ACLR). METHODS A literature search was performed systematically using PubMed, Embase, and Medline databases in April 2022. The search included the following terms combined with Boolean operators: 'Meniscus repairs', 'Meniscal Repair', 'Posterior Horn', 'Root', 'Radial'. Inclusion criteria consisted of level I-IV human clinical and biomechanical studies reporting biomechanical data and/or outcomes following LMPR repair in the setting of ACLR. RESULTS Three biomechanical studies, all utilizing a transtibial pullout technique, were identified, all of which reported significant improvement in joint contact pressures and mechanics and 3/4 of which reported significant improvement in anterior or rotational stability with LMPR repair. Five clinical studies, consisting of 146 patients (mean age 28.5 ± 1.1 years) undergoing LMPR repair, were identified with an average follow-up of 19.1 months (range 6.2-46 months). Across all clinical studies, Lysholm and International Knee Documentation Committee (IKDC) scores were found to improve postoperatively, with 3/4 reporting significant improvement in Lysholm (all, p ≤ 0.001) scores and 3/5 reporting significant improvement in IKDC scores when compared to preoperative values (all, p ≥ 0.004). Meniscal extrusion decreased significantly following repair in 2/4 studies (all, p ≤ 0.001). CONCLUSIONS Biomechanically, transtibial pullout repair of the LMPR restored joint contact pressures and joint mechanics to intact levels when performed with concomitant ACLR. Clinically, LMPR repair with concurrent ACLR resulted in improved Lysholm and IKDC scores. These findings enable surgeons to determine optimal treatment plans and discuss realistic outcomes with patients when encountering LMPR injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Allison K Perry
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA.
| | - Derrick M Knapik
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Bhargavi Maheshwer
- University of Cincinnati College of Medicine, Cincinnati, OH, 45219, USA
| | - Evan M Polce
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53726, USA
| | - Alexander J Hodakowski
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Garrett Jackson
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA.
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Wilder JH, Ofa SA, Lee OC, Gadinsky NE, Rodriguez RF, Sherman WF. Rates of Operative Management for Achilles Tendon Rupture Over the Last Decade and the Influence of Gender and Age. Foot Ankle Spec 2023; 16:377-383. [PMID: 35695472 DOI: 10.1177/19386400221102745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND With emerging evidence supporting functional rehabilitation for Achilles tendon ruptures (ATRs), this study sought to evaluate the treatment trends for patients sustaining an acute ATR and whether gender and age may influence the rates of operative repair. METHODS A retrospective database review identified ATRs from 2010 through 2019. Patients were then stratified into three cohorts based on age (18-30, 30-45, and 46 and older), separated by gender, and then assessed whether patients were treated operatively or not. Cochran-Armitage Trend test was performed to analyze the trends of operative management. Chi-square analyses were performed to assess whether the proportion of patients who received operative management in each age cohort differed from 2010 to 2019. Logistic regression analyses were performed to assess whether gender influenced treatment. RESULTS Over the previous decade, the total rates of operative treatment for ATR significantly decreased (18.3%-12.3%, P < .0001). Each individual age cohort experienced a proportional decrease in operative management when comparing 2010 with 2019 (all P < .0001). Within all age cohorts, males were significantly more likely to receive operative treatment for an ATR over the previous decade (odds ratios: 2.63-3.22). Conclusion. Overall rates of operative management for ATR decreased across all cohorts likely due to previous studies providing evidence of similar results between operative and nonoperative managements. Over the previous decade, males were demonstrated to be far more likely than females to undergo operative management. Why females are less likely to receive an operation for ATR is likely multi-factorial and requires further exploration. LEVEL OF EVIDENCE Level III: Retrospective comparative study.
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Affiliation(s)
- J Heath Wilder
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sione A Ofa
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
- Department of Orthopaedic Surgery, Louisiana State University School of Medicine and Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
| | - Naomi E Gadinsky
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ramon F Rodriguez
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Moore ML, Hawkins RJ, Pollock JR, Makovicka JL, Haglin JM, Brinkman JC, Patel KA. Bibliometric Analysis of the Top 50 Most Cited Studies on Achilles Tendon Pathology. Orthop J Sports Med 2023; 11:23259671221134117. [PMID: 37223074 PMCID: PMC10201170 DOI: 10.1177/23259671221134117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 08/10/2022] [Indexed: 05/25/2023] Open
Abstract
Background The development of Achilles tendon treatment modalities has been rapid, and it is increasingly difficult for clinicians to stay up to date with the most influential studies in this field. In order to fully understand the current state of the literature regarding Achilles tendon injury, it is invaluable to be familiar with the foundational articles and studies upon which the field is built. Purpose To objectively determine the 50 most frequently cited studies in Achilles tendon pathology and to conduct a bibliometric analysis. Study Design Cross-sectional study. Methods The Clarivate Analytics Web of Knowledge database was used to gather data and metrics of Achilles tendon research. The 50 most cited articles were selected for analysis from an initial 17,244 identified articles. The information extracted for each article included author name, publication year, country of origin, journal name, study type, and level of evidence. Results For these 50 studies, the total number of citations was calculated to be 13,159, with a mean of 263.2 citations per paper. The most cited article collected 657 citations. The publication dates of the 50 studies included in this analysis spanned 41 years (1972-2013). The largest number of articles were published by Swedish authors (n = 14); however, many other countries were represented, including Canada and Finland (n = 6 articles each). The most prevalent study designs were cohort studies (n = 13) with level 4 evidence studies being the most common (n = 14). Conclusion Among the 50 most influential articles in Achilles tendon pathology, the study designs most commonly used were cohort studies and review articles. Sweden was the country of origin for the most studies included on this list, which reflects this country's interest and commitment to researching Achilles tendon injuries and treatments.
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Affiliation(s)
- M. Lane Moore
- Mayo Clinic Alix School of Medicine,
Scottsdale, Arizona, USA
| | | | | | - Justin L. Makovicka
- Department of Orthopedic Surgery, Mayo
Clinic Arizona, Phoenix, Arizona, USA
| | - Jack M. Haglin
- Department of Orthopedic Surgery, Mayo
Clinic Arizona, Phoenix, Arizona, USA
| | - Joseph C. Brinkman
- Department of Orthopedic Surgery, Mayo
Clinic Arizona, Phoenix, Arizona, USA
| | - Karan A. Patel
- Department of Orthopedic Surgery, Mayo
Clinic Arizona, Phoenix, Arizona, USA
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Seow D, Islam W, Randall GW, Azam MT, Duenes ML, Hui J, Pearce CJ, Kennedy JG. Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07411-1. [PMID: 37115231 DOI: 10.1007/s00167-023-07411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/30/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR. METHODS Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance. RESULTS There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation. CONCLUSION This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Dexter Seow
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wasif Islam
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Grace W Randall
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Mohammad T Azam
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Matthew L Duenes
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - James Hui
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher J Pearce
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - John G Kennedy
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA.
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Shoap S, Backer HC, Freibott CE, Ferrer XE, Polzer H, Turner Vosseller J. Rerupture and wound complications following Achilles tendon repair: A systematic review. J Orthop Res 2023; 41:845-851. [PMID: 35864743 DOI: 10.1002/jor.25419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/06/2022] [Accepted: 07/16/2022] [Indexed: 02/04/2023]
Abstract
Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.
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Affiliation(s)
- Seth Shoap
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida, USA
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Henrik C Backer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Christina E Freibott
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Xavier E Ferrer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Hans Polzer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - James Turner Vosseller
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- Jacksonville Orthopaedic Institute, Jacksonville, Florida, USA
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Reingrittha P, Benjawongsathien K, Visuthisakchai S. The Efficacy of Posterior Fasciotomy Versus Inserted Vacuum Drainage in Reducing Postoperative Surgical Site Infection in Open Achilles Tendon Repair: A Prospective Cohort Study With Inverse Probability Treatment Weight Propensity Score Analysis. J Foot Ankle Surg 2023; 62:222-227. [PMID: 35918264 DOI: 10.1053/j.jfas.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 02/03/2023]
Abstract
Posterior crural fasciotomy (PF) may reduce postoperative surgical site infection (SSI) rate compared to inserted vacuum suction drainage (VD) in open Achilles tendon repair surgery. Thus, we aimed to compare the postoperative SSI rate between PF and VD in open Achilles's tendon repair surgery. A prospective, single-centered, nonrandomized controlled study of consecutive adult patients undergoing primary open Achilles tendon repair was performed at tertiary referral hospital between January 2017 and January 2020. Patients received either PF or VD from 2 experienced surgeons. Data were collected on demographic, clinical, and intraoperative characteristics along with postoperative SSI and other outcomes. The primary outcome was SSI rate. Secondary outcomes were Achilles tendon total rupture score, functional foot index, and visual analogue scale. A total of 60 patients were eligible and included in the final analysis (PF group n = 30 and VD group n = 30). Two (6.7%) patients in the PF group and 5 (16.7%) patients in the VD group experience postoperative SSI (crude risk ratio 0.40; 95% confidence interval 0.08, 1.90; p = .228). In inverse-probability-treatment-weighted propensity score analysis, the PF group had a significantly lower SSI rate than the VD group (adjusted risk ratio 0.30; 95% confidence interval 0.01, 0.91; p = .033). Inverse-probability-treatment-weighted propensity score analysis of Achilles tendon total rupture score along with crude analysis of total functional foot index and visual analogue scale were also significantly better in the PF group than the VD group (all p < .05). PF during open Achilles repair was associated with a significant reduction in postoperative SSI infection rate compared to VD.
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Kumar P, Kagan BD, Michelson JD. Surgical versus nonsurgical treatment of acute Achilles ruptures in the high demand patient: Using decision analysis to help clinical decisions. Foot Ankle Surg 2023; 29:213-217. [PMID: 36646593 DOI: 10.1016/j.fas.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/11/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Recent literature suggests that functional treatment of acute non-insertional Achilles tendon ruptures yields outcomes (re-rupture and function) similar to those of surgery, but does not address the unique issues in treating high performance athletes or other high demand patients. METHODS Decision analysis was used to develop an estimate of outcome utility for both types of treatment using published Costs and Quality-Adjusted Life Years (QALYs) values. The expected value for either treatment was then calculated for high, intermediate, and normal demand patients, using the specific functional needs of the patients. RESULTS Nonoperative treatment is the preferred management for normal demand patients, while high and intermediate demand patients are more likely to experience better expected functional outcomes from surgery. CONCLUSION The combination of a decision analysis and expected value analysis provides evidence-based support for the existing intuitive recommendations that favor surgical treatment in elite athletes and other high demand patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Prasanna Kumar
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Benjamin D Kagan
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - James D Michelson
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA.
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Moore ML, Pollock JR, Karsen PJ, Haglin JM, Lai CH, Elahi MA, Chhabra A, O’Malley MJ, Patel KA. Open Achilles Tendon Repair. JBJS Essent Surg Tech 2023; 13:e21.00054. [PMID: 38274281 PMCID: PMC10807880 DOI: 10.2106/jbjs.st.21.00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Background An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury-and the resulting open repair-are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible. Description Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion. Alternatives Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport1,2. Rationale Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair3. Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness)2. Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment. Expected Outcomes Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al.4, 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no reruptures. In a recent meta-analysis by Meulenkamp et al.5, the authors found that operative repair of Achilles tendon rupture was associated with a reduced risk of rerupture compared with primary immobilization (i.e., conventional cast immobilization with delayed weight-bearing for at least 6 weeks only). However, open surgical repair, minimally invasive repair, and functional rehabilitation all had similar risk of rerupture5. In a review by Ochen et al.6 that analyzed 29 studies with a total of 15,862 patients, operative repair was associated with a significantly lower risk of rerupture compared with nonoperative treatment (2.3% versus 3.9%, respectively). However, operative treatment was also associated with a significantly higher complication rate compared with nonoperative treatment (4.9% versus 1.6%, respectively)6. Finally, in a meta-analysis by Soroceanu et al.7, the authors found that if early range-of-motion protocols and functional rehabilitation were utilized, operative and nonoperative treatment resulted in similar outcomes and equivalent rates of rerupture. Important Tips To prevent rerupture of an Achilles tendon, remind patients to engage in adequate stretching and warming prior to physical activity.Palpate and locate the tendon defect prior to making the first incision.Immobilize the ankle joint in a splint for 2 weeks postoperatively in maximum plantar flexion.Pitfalls include:○ Poor suture management leading to tangling in the repair.○ Undertensioning or overtensioning of the repair, which can be avoided by sterilely draping out both legs and checking resting tension intraoperatively.○ Failure to close the paratenon, causing scarring of the skin or surrounding tissues, which can be avoided by making a relieving incision on the deep surface of the paratenon.○ Leaving suture knots on the dorsal side of the repair that may aggravate the skin. Acronyms & Abbreviations MRI = magnetic resonance imagingESU = electrosurgical unit.
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Affiliation(s)
- M. Lane Moore
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | | | | | - Jack M. Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Cara H. Lai
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Martin J. O’Malley
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Karan A. Patel
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
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11
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Murdock CJ, Ochuba AJ, Xu AL, Snow M, Bronheim R, Vulcano E, Aiyer AA. Operative vs Nonoperative Management of Achilles Tendon Rupture: A Cost Analysis. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231156410. [PMID: 36911422 PMCID: PMC9998413 DOI: 10.1177/24730114231156410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Background Achilles tendon rupture (ATR) is a common injury with a growing incidence rate. Treatment is either operative or nonoperative. However, evidence is lacking on the cost comparison between these modalities. The objective of this study is to investigate the cost differences between operative and nonoperative treatment of ATR using a large national database. Methods Patients who received treatment for an ATR were abstracted from the large national commercial insurance claims database, Marketscan Commercial Claims and Encounters Database (n = 100 825) and divided into nonoperative (n = 75 731) and operative (n = 25 094) cohorts. Demographics, location, and health care charges were compared using multivariable regression analysis. Subanalysis of costs for medical services including clinic visits, imaging studies, opioid usage, and physical therapy were conducted. Patients who underwent secondary repair were excluded. Results Operative treatment was associated with increased net and total payments, coinsurance, copayment, deductible, coordination of benefits (COB) / savings, greater number of clinic visits, radiographs, magnetic resonance imaging (MRI) scans, and physical therapy (PT) sessions, and with higher net costs due to clinic visits, radiographs, MRIs, and PT (P < .001). Operative repair at an ambulatory surgical center was associated with a lower net and total payment, and a significantly higher deductible compared to in-hospital settings (P < .001). Both cohorts received similar numbers of opioid prescriptions during the study period. Yet, operative patients had a significantly shorter duration of opioid use. After controlling for confounders, operative repair was also independently associated with lower net costs due to opioid prescriptions. Conclusion Compared with nonoperatively managed ATR, surgical repair is associated with greater costs partially because of greater utilization of clinic visits, imaging, and physical therapy sessions. However, surgical costs may be reduced when procedures are performed in ambulatory surgery centers vs hospital facilities. Nonoperative treatment is associated with higher prescription costs secondary to longer duration of opioid use. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
| | - Arinze J. Ochuba
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Amy L. Xu
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Morgan Snow
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Rachel Bronheim
- The Johns Hopkins Hospital, Orthopaedic Surgery, Baltimore, MD, USA
| | - Ettore Vulcano
- Mount Sinai Medical Center, Orthopaedic Surgery, Miami, FL, USA
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12
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Bach S, Biedlingmaier R. Achilles tendon rupture: A case report. Nurse Pract 2022; 47:13-17. [PMID: 36006813 DOI: 10.1097/01.npr.0000855296.82906.ab] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Jun L, Hao Y, Junfeng Z, Jisen Z, Xinzhong X, Yunfeng Y, Dasheng T, Jia X. Comparison of Ma-Griffith combined with a minimally invasive small incision to a modified suture technique for the treatment of acute achilles tendon ruptures. BMC Musculoskelet Disord 2022; 23:822. [PMID: 36042433 PMCID: PMC9425948 DOI: 10.1186/s12891-022-05769-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background The Achilles tendon is the strongest tendon in the human body, although it is also prone to injury and rupture. Currently, the best treatment method for acute Achilles tendon rupture remains controversial. The aim of this study was to compare the efficacy of the Ma-Griffith method combined with a minimally invasive small incision (M-G/MISI) with the modified suture technique (MST). Methods We conducted a retrospective review of the medical records of all patients who underwent treatment for acute Achilles tendon rupture between January 2012 and January 2020 at our hospital. Demographic characteristics, operative details, and postoperative complications were recorded, and data were statistically analyzed to compare the treatment efficacy of the two operative methods. Results A total of 67 patients were enrolled in the study, 34 of whom underwent M-G/MISI treatment, and 33 of whom underwent MST treatment. The intraoperative blood loss in the M-G/MISI group (16.47 ± 13.23 ml) was significantly lower than that in the MST group (34.55 ± 13.01 ml), and the difference was statistically significant (P ˂0.001). The incision in the M-G/MISI group (3.79 ± 1.81 cm) was significantly shorter than that in the MST group (5.79 ± 1.00 cm), and the difference was statistically significant (P˂0.001). The Achilles tendon rupture score and the American Orthopedic Foot and Ankle Society (AOFAS) score were higher than those of the MST group at the sixth month after the operation (P˂0.001). Postoperatively, there was 1 case of traumatic Achilles tendon rupture in the M-G/MISI group and 1 case each of infection and deep vein thrombosis in the modified suture group. Conclusions Compared with the MST group, the M-G/MISI group had better Achilles tendon and ankle function scores at 6 months postoperatively, and less bleeding and shorter incisions. M-G/MISI is less invasive than MST.
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Affiliation(s)
- Li Jun
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China
| | - Yu Hao
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China
| | - Zhan Junfeng
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China
| | - Zhang Jisen
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China
| | - Xu Xinzhong
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China
| | - Yao Yunfeng
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China
| | - Tian Dasheng
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China
| | - Xie Jia
- Department of Orthopedics, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, 230601, Anhui, Hefei, People's Republic of China.
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14
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de Oliveira PR, Arrebola LS, Stéfani KC, Pinfildi CE. Photobiomodulation Associated With Conservative Treatment for Achilles Tendon Rupture: A Double-Blind, Superiority, Randomized Controlled Trial. Arch Rehabil Res Clin Transl 2022; 4:100219. [PMID: 36545533 PMCID: PMC9761261 DOI: 10.1016/j.arrct.2022.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective To investigate the effects of photobiomodulation on Achilles tendon rupture (ATR) treated conservatively. Design Prospective, patient- and assessor-blinded, parallel, randomized controlled trial. Setting Patients with acute ATR treated conservatively. Participants Thirty-four male individuals with acute unilateral ATR treated conservatively (N=34), equally divided in 2 groups: photobiomodulation group (PBMG) and sham group, with mean age of 45.5±9.47 and 48.7±8.38 years, respectively. Intervention All participants underwent through an immobilization period, followed by rehabilitation sessions (2 d/wk for 12 weeks) comprising strengthening, range of motion, and balance/weightbearing exercises. In PBMG, the tendon was irradiated with a photobiomodulation cluster (1 904 nm/50 mW infrared laser, 4 858 nm/50 mW infrared diodes, and 4 658 nm/40 mW red diodes; power density of 105 mW/cm2 per cluster area) during the immobilization period (2 d/wk for 8 weeks) and the sham group received a simulation of the procedure with no irradiation. Outcomes were assessed at the removal of the immobilization 12 and 16 weeks after tendon rupture. Main Outcome Measures Primary outcome was the Achilles Tendon Rupture Score. Secondary outcomes included Numerical Pain Rating Scale at rest and during effort, plantar flexor strength, and ankle range of motion. Results Both groups demonstrated an increase in the Achilles Tendon Rupture Score and improvements in range of motion, plantar flexor strength, and pain. There were no significant differences in outcomes between the 2 groups (P>.05) except in pain during walking, which was significantly lower in the PBMG in week 12 (P<.01, effect size=0.56) and week 16 (P<.01, effect size=0.55). Conclusion Photobiomodulation associated with conservative treatment is not superior to conservative treatment alone for improving function in patients with acute ATR.
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Key Words
- ATR, Achilles tendon rupture
- ATRS, Achilles Tendon Rupture Score
- Achilles tendon
- CI, confidence interval
- ES, effect size
- IAMSPE, Institute of Medical Assistance to the State Public Servant
- Low-level light therapy
- NPRS, Numerical Pain Rating Scale
- PBM, photobiomodulation
- PBMG, photobiomodulation group
- ROM, range of motion
- Rehabilitation
- SG, sham group
- WALT, World Association for Photobiomodulation Therapy
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Affiliation(s)
- Pedro Rizzi de Oliveira
- Department of Human Movement Sciences, Federal University of São Paulo (UNIFESP), Baixada Santista Campus, São Paulo,Physical Therapy Department, Institute of Medical Assistance to the State Public Servant (IAMSPE), São Paulo,Corresponding author Pedro Rizzi de Oliveira, PT, MSc, Department of Human Movement Sciences, Federal University of São Paulo (UNIFESP), Rua Silva Jardim, 136 Vila Matias, Santos, São Paulo 11015-020.
| | - Lucas Simões Arrebola
- Department of Human Movement Sciences, Federal University of São Paulo (UNIFESP), Baixada Santista Campus, São Paulo,Physical Therapy Department, Institute of Medical Assistance to the State Public Servant (IAMSPE), São Paulo
| | - Kelly Cristina Stéfani
- Center of Technological Innovation, University of Sao Paulo Hospital of Clinics (HC-FMUSP), São Paulo, Brazil
| | - Carlos Eduardo Pinfildi
- Department of Human Movement Sciences, Federal University of São Paulo (UNIFESP), Baixada Santista Campus, São Paulo
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15
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Mansfield K, Dopke K, Koroneos Z, Bonaddio V, Adeyemo A, Aynardi M. Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play. Curr Rev Musculoskelet Med 2022; 15:353-361. [PMID: 35804260 DOI: 10.1007/s12178-022-09774-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport. RECENT FINDINGS The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.
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Affiliation(s)
- Kirsten Mansfield
- Center for Orthopaedic Research and Translational Science, The Pennsylvania State University, 500 University Drive, H089, Hershey, PA, 17033, USA
| | - Kelly Dopke
- Center for Orthopaedic Research and Translational Science, The Pennsylvania State University, 500 University Drive, H089, Hershey, PA, 17033, USA
| | - Zachary Koroneos
- Center for Orthopaedic Research and Translational Science, The Pennsylvania State University, 500 University Drive, H089, Hershey, PA, 17033, USA
| | - Vincenzo Bonaddio
- Penn State Milton Hershey Medical Center Department of Bone and Joint, 30 Hope Drive, Building A; PO Box 859, Hershey, PA, 17033, USA
| | - Adeshina Adeyemo
- Penn State Milton Hershey Medical Center Department of Bone and Joint, 30 Hope Drive, Building A; PO Box 859, Hershey, PA, 17033, USA
| | - Michael Aynardi
- Penn State Milton Hershey Medical Center Department of Bone and Joint, 30 Hope Drive, Building A; PO Box 859, Hershey, PA, 17033, USA.
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16
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Reito A, Mattila V, Karjalainen T. Operative vs Nonoperative Treatment of Achilles Tendon Ruptures Using Early Functional Rehabilitation: Critical Analysis of Evidence. Foot Ankle Int 2022; 43:887-890. [PMID: 35382647 DOI: 10.1177/10711007221083691] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative treatment with functional rehabilitation of Achilles tendon ruptures (ATRs) has become more common because of claim of "equivalent" risk of rerupture compared to operative treatment. We investigated how current evidence corroborates the often-claimed "equal" or "nondifferent" complication rates. METHODS A search of meta-analyses in PubMed, CENTRAL, and Scopus was performed. Meta-analyses including randomized controlled trials (RCTs) comparing open operative repair of ATR and nonoperative treatment with functional rehabilitation regarding reruptures and other complications were identified. RESULTS Four separate meta-analyses with 6 pooled treatment comparisons were identified. One of the 6 treatment effects (for risk ratio [RR]) showed a reduced risk of rerupture favoring operative treatment, whereas in the remaining analyses the null hypothesis assuming equal risk or an RR of 1 could not be rejected. The smallest RR (benefit in favor of surgery) that could be rejected based on the 95% CI was 0.28. The smallest risk difference that could be rejected in favor of surgery was 6.4%, indicating that nonoperative may have up to 6.4% higher rerupture rate. Treatment effects for complications other than rerupture had very large variability and imprecision. CONCLUSION The literature comparing surgery with nonoperative treatment using functional rehabilitation in ATR have been interpreted in favor of nonoperative treatment as the rerupture rates were falsely considered "equivalent." None of the published meta-analyses excluded a relative risk that is likely to affect the course of treatment in many cases. Increasing incidence of nonoperative treatment in ATRs is not clearly supported by current evidence.
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Affiliation(s)
- Aleksi Reito
- Department of Orthopaedics and Traumatology, Faculty of Medicine and Health Technology, Tampere University Hospital, University of Tampere, Tampere, Finland
| | - Ville Mattila
- Department of Orthopaedics and Traumatology, Faculty of Medicine and Health Technology, Tampere University Hospital, University of Tampere, Tampere, Finland
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17
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Feeley AA, Feeley IH, Roopnarinesingh R, Bayer T. Rates of complications in Achilles tendon rupture repair using absorbable and nonabsorbable suture material; A systematic review. Foot (Edinb) 2022; 51:101875. [PMID: 35461151 DOI: 10.1016/j.foot.2021.101875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/17/2021] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The impact of suture type on tensile strength, re-rupture rates and infection risk in Achilles tendon rupture repair is not been well established. The aim of this review is to evaluate existing literature on the associated risk of postoperative infection with absorbable and non-absorbable suture materials in Achilles tendon rupture repair. METHODS A systematic review of search databases PubMed; Google Scholar; and OVID Medline was made to identify studies related to complications associated with Achilles tendon rupture repair. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare rupture rates and infections following rupture repair. RESULTS 12 studies with a total of 460 patients, 230 in both nonabsorbable and absorbable suture groups were included for analysis. Risk of wound complications was significantly higher in patients with non-absorbable sutures (p < 0.001). CONCLUSION Nonabsorbable braided sutures is associated with the highest risk of postoperative wound complications following Achilles tendon rupture repair.
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Affiliation(s)
- Aoife A Feeley
- Midland Regional Hospital Tullamore, Arden Rd, Puttaghan, Tullamore, Co. Offaly, R35 NY51, Ireland; University College Dublin, Belfield, Dublin 4, Ireland.
| | - Iain H Feeley
- National Orthopaedic Hospital Cappagh, Cappagh Rd, Cappoge, Dublin 11, D11 EV29, Ireland
| | - Ryan Roopnarinesingh
- Midland Regional Hospital Tullamore, Arden Rd, Puttaghan, Tullamore, Co. Offaly, R35 NY51, Ireland
| | - Thomas Bayer
- Midland Regional Hospital Tullamore, Arden Rd, Puttaghan, Tullamore, Co. Offaly, R35 NY51, Ireland
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18
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Chen HY, Ao YF, Yang YP. Delayed Wound Healing After Achilles Tendon Suture: An Arthroscopic Solution. Arthrosc Tech 2022; 11:e397-e402. [PMID: 35256982 PMCID: PMC8897600 DOI: 10.1016/j.eats.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023] Open
Abstract
This technical note describes an arthroscopic technique for treating delayed wound healing after Achilles tendon suture. Ankle arthroscopy is used to clean up the inflammatory tissues and foreign bodies that lead to delayed wound healing, with the advantages of simple postoperative care and low infection risk. This method may provide a less traumatic and low-risk option for the treatment of delayed wound healing after Achilles tendon surgery. The purpose of this technical note is to describe surgical procedures and related recommendations.
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Affiliation(s)
- Hong-yu Chen
- Peking University Health Science Center, Beijing, P.R. China
| | - Ying-fang Ao
- Department of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, P.R. China,Addresses correspondence to Yu-ping Yang, M.D., 49 North Garden Rd., Haidian District, Beijing, P.R. China; Ying-fang Ao, M.D., 49 North Garden Rd., Haidian District, Beijing, P.R. China.
| | - Yu-ping Yang
- Department of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, P.R. China
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19
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Yu H, Wang F, Xie J, Yao Y, Jing J, Li J. The Reinforced Ma-Griffith Method Combined with Minimally Invasive Small-Incision Suture for Acute Achilles Tendon Rupture. Orthop Surg 2021; 14:315-322. [PMID: 34939329 PMCID: PMC8867432 DOI: 10.1111/os.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 11/28/2022] Open
Abstract
Objective To evaluate the treatment effects of the reinforced Ma‐Griffith method combined with a minimally invasive small incision(M‐G/MISI) in the treatment of acute Achilles tendon rupture. Methods From January 2012 to January 2020, a retrospective study was carried out on thirty‐one patients with acute Achilles tendon ruptures that were treated using the M‐G/MISI. Patient with acute Achilles tendon rupture was operated on in the prone position. The M‐G/MISI begin with making a small incision to debride the stumps of ruptured tendon. Then M‐G/MISI was used to suture the distal and proximal Achilles tendons with the help of a epidural puncture needle and polydioxanone synthetic absorbable suture (PDS) Ⅱ line. Finally the stumps of ruptured tendon was reattached. After the surgery, the affected limb was fixed with either a plaster slab below the knee brace or a functional brace. Removal of plaster external fixation and partial weight‐bearing with crutches five weeks after the operation; Complete weight‐bearing nine weeks after the operation; jogging permitted 12 weeks after the operation; Patients were allowed to resume normal activities six months after the operation. Results All 31 patients in this study were male. Nineteen of these patients had Achilles tendon rupture on the right lower extremity, while 12 had ruptures on the left lower extremity. The patients had a mean age of 33.35 ± 7.13 years (range, 18‐52 years). The mean operation time was 79.58 ± 22.67 minutes (range, 40‐167 minutes). The mean time from injury to operation was 4.19 ± 2.01 days (range, 1‐8 days), and the mean hospital stay was 9.87 ± 3.88 days (range, 5‐22 days). The new technique had a small incision with a mean length of 3.94 ± 1.82 cm (range, 2‐6 cm). The mean intraoperative blood loss was 16.77 ± 13.76 mL (range, 10‐50 mL) and the mean follow‐up time was 21.35 ± 10.18 months (range, 6‐50 months). No wound infection, fistula, skin necrosis, sural nerve damage, deep venous thrombosis or tendon re‐rupture was found. One year after the surgery, all patients reported 97.00 (range, 93‐100 points) AOFAS ankle‐hindfoot score points and the mean ATRS was 97.39 (range, 91‐100) points. Conclusion The reinforced Ma‐Griffith method, combined with a minimally invasive small incision suture, is a simple, effective, minimally invasive technique and low‐cost surgical method for the treatment of acute Achilles tendon rupture.
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Affiliation(s)
- Hao Yu
- Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Fangyuan Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jia Xie
- Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yunfeng Yao
- Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Juehua Jing
- Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jun Li
- Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
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20
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Park HG, Youn D, Baik JM, Hwang JH. Epidemiology of Achilles Tendon Rupture in South Korea: Claims Data of the National Health Insurance Service from 2009 to 2017. Clin Orthop Surg 2021; 13:539-548. [PMID: 34868504 PMCID: PMC8609222 DOI: 10.4055/cios20255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 12/15/2022] Open
Abstract
Background The incidence of Achilles tendon rupture and its trend has not been studied in Asia. The purpose of this nationwide study was to analyze the trend of incidence and surgical treatment of tendon ruptures in South Korea based on sex, age, and income level of patients, as well as seasonal variation. Methods A descriptive epidemiologic study was performed based on the data collected retrospectively from the Korea National Health Insurance Service. Data of all outpatients and inpatients were collected from approximately 52 million residents of South Korea, primarily diagnosed with Achilles tendon rupture from 2009 to 2017. Results A total of 112,350 patients had Achilles tendon rupture, of which 44,248 patients underwent surgical treatment during the study period. The overall, age-specific, and sex-specific incidence of Achilles tendon rupture and surgical treatment showed an increasing trend. Patients in the age group of 41 to 50 years showed the highest increase in incidence. Regarding season, higher incidence was reported during spring and summer, whereas the lowest incidence was found in winter. Higher income level was associated with increased incidence of the condition. Conclusions The incidence of Achilles tendon rupture and surgical treatments increased rapidly in patients between 41 and 50 years of age. Patients in the higher income quintile groups experienced more Achilles tendon injury than those in lower income groups, and fewer ruptures were observed during winter.
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Affiliation(s)
- Hong-Gi Park
- Department of Orthopaedic Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | | | - Jong-Min Baik
- Department of Orthopaedic Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jae Ho Hwang
- Department of Orthopaedic Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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21
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Seow D, Yasui Y, Calder JDF, Kennedy JG, Pearce CJ. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med 2021; 49:3728-3748. [PMID: 33783229 DOI: 10.1177/0363546521998284] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling. PURPOSE To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 1. METHODS Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%). RESULTS Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications. CONCLUSION This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.
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Affiliation(s)
- Dexter Seow
- National University Health System, Singapore
| | - Youichi Yasui
- Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan
| | - James D F Calder
- Fortius Clinic, London, UK.,Department of Bioengineering, Imperial College London, London, UK
| | - John G Kennedy
- NYU Langone Orthopedic Hospital, New York, New York, USA
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Oppy A, Mohtadi N, Buckley R. Achilles tendon rupture in a healthy 37yo male. Injury 2021; 52:2756-2758. [PMID: 34719427 DOI: 10.1016/j.injury.2020.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew Oppy
- Royal Melbourne Hospital - Orthopedic Department, Grattan Street, Melbourne 3050, Australia
| | - Nick Mohtadi
- Dip. Sport Med; Clinical Professor in Orthopaedics, Department of Surgery, Cumming School of Medicine; Adjunct Professor Faculty of Kinesiology; Medical Director Sport Medicine Centre, University of Calgary, Alberta, Canada
| | - Richard Buckley
- Clinical Professor in Orthopedics, Department of Surgery, Cumming School of Medicine, University of Calgary, 0490 McCaig Tower, 3134 Hospital Drive NW, Foothills Hospital, Calgary, Alberta, Canada.
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Wei S, Chen J, Kong C, Xu F, Zhi X, Cai X. Endoscopic "internal splinting" repair technique for acute Achilles tendon rupture. Arch Orthop Trauma Surg 2021; 141:1753-1760. [PMID: 33594461 DOI: 10.1007/s00402-021-03818-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/01/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Recently, endoscopically assisted Achilles tendon repair techniques have improved to overcome the surgical complications. However, the risk of sural nerve injury and the strength of repair are still the most concerning aspects. MATERIAL AND METHODS Twenty three patients with acute Achilles tendon rupture were reviewed in the present study. We stitch the Achilles tendon above the ruptured site using the endoscopic locking loop suture technique, and the knotless anchor suture-bridge technique can be used to make the distal fixation of threads. The function was assessed using the muscle power (MRC0-5), ATRS scores, AOFAS ankle-hindfoot scores, and VAS scores at the final follow-up. RESULTS The mean follow-up time was 15.74 ± 2.43 months (12-18). At the final follow-up, the average of the muscle power (MRC0-5), ATRS score, AOFAS ankle-hindfoot score, and VAS score are 4.74 ± 0.45, 97.83 ± 2.77, 96.52 ± 4.87, and 0.35 ± 0.49, respectively. Every patient returned to previous sports activity at 6 months postoperative. No wound infection and sural nerve injuries were encountered. Only one case suffers local irritation at the medial knotless anchor site. CONCLUSIONS Endoscopic "internal splinting" repair for acute Achilles tendon rupture using locking loop stitch with suture-bridge technique leads to an expedited return to activity with a low risk of complications. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Shijun Wei
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China. .,Guangdong, The First Clinical Medical School of Southern Medical University, Guangzhou, People's Republic of China.
| | - Jia Chen
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China
| | - Changwang Kong
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China
| | - Feng Xu
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China. .,Guangdong, The First Clinical Medical School of Southern Medical University, Guangzhou, People's Republic of China.
| | - Xiaosong Zhi
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China
| | - Xianhua Cai
- Department of Orthopaedics, General Hospital of Central Theater Command (Wuhan General Hospital of Guangzhou Command, previously), Hubei, No. 627, Wuluo Road, Wuhan, 430030, People's Republic of China.,Guangdong, The First Clinical Medical School of Southern Medical University, Guangzhou, People's Republic of China
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Julies E, Williams T, Hall S. The Surgical Care Practitioner role in Achilles tendon re-rupture: A case study. J Perioper Pract 2021; 31:454-462. [PMID: 34478332 DOI: 10.1177/17504589211002377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The value of a Surgical Care Practitioner to an orthopaedic team is demonstrated in this case study of a patient who presented with a re-ruptured Achilles tendon. It highlights the role the practitioner plays in the patient journey and illustrates it's value throughout the clinical course from consultation through to discharge. The Surgical Care Practitioner, as a member of the extended surgical team can help to explain the diagnosis and associated treatment options, facilitate informed consent and provide expert procedural assistance to the surgeon. A Surgical Care Practitioner is ideally placed to answer patient queries and aid in rehabilitation.
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Affiliation(s)
- Elda Julies
- Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Tim Williams
- Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Susan Hall
- Anglia Ruskin University, Chelmsford, UK
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Fischer S, Kutscher R, Gramlich Y, Klug A, Hoffmann R, Manegold S. Secondary reconstruction of chronic Achilles tendon rupture: flexor hallucis longus transfer versus plantaris longus augmentation. INTERNATIONAL ORTHOPAEDICS 2021; 45:2323-2330. [PMID: 34269822 DOI: 10.1007/s00264-021-05128-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Chronic Achilles tendon rupture is primarily caused by degenerative processes of multifactorial origin. In addition to secondary repair (SR) with augmentation of the plantaris longus tendon, the transfer of the flexor hallucis longus tendon (FHL) to the calcaneus is a recognised reconstruction procedure. This paper aims to provide a direct comparison based on clinical scores and objectifiable strength measurements. METHODS We analysed data for 60 patients (46 males and 14 females) with chronic Achilles tendon rupture, including 34 (mean age 57 years) treated with FHL and 26 (mean age 52 years) with SR between 2016 and 2020 (mean follow-up of 49 months). The follow-up included the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scoring System (AOFAS-AH) and Visual Analogue Scale Foot and Ankle (VAS FA), the 12-item Short Form Survey (SF-12) and the objectifiable strength measurement using the dynamometer BIODEX®. Pre-existing gait disorders and permanent pain therapy led to exclusion. RESULTS The mean AOFAS-AH was 87.8 points (FHL: 85.6, SR: 90.6), the mean VAS FA was 78.1 points (FHL: 73.7, SR: 83.6), the mean PCS was 48.2 points (FHL: 46.3, SR: 50.7) and the mean MCS was 54.1 points (FHL: 55.0, SR: 53.0). The maximum torque for plantar flexion was 56.7 Nm on average (FHL: 51.0, SR: 63.7). A total of seven (11.7%) wound infections requiring revision occurred (FHL: 4 (11.8%), SR: 3 (11.5%)). All measurements did not differ significantly between the groups (p > 0.05). CONCLUSION The results of the study prove the equivalence of FHL and SR based on the clinical scores as well as on the strength measurement using BIODEX®. Nevertheless, a higher withdrawal because of morbidity with a tendency for prolonged incapacity to work in the FHL group has to be taken into account. The present work provides the basis for a prospective comparison in future studies.
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Affiliation(s)
- Sebastian Fischer
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| | - Rahel Kutscher
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Yves Gramlich
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Frankfurt, Germany
| | - Alexander Klug
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Frankfurt, Germany
| | - Reinhard Hoffmann
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Frankfurt, Germany
| | - Sebastian Manegold
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
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Shi F, Wu S, Cai W, Zhao Y. Multiple comparisons of the efficacy and safety for six treatments in Acute Achilles Tendon Rupture patients: A systematic review and network meta-analysis. Foot Ankle Surg 2021; 27:468-479. [PMID: 32732151 DOI: 10.1016/j.fas.2020.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/21/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS 38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens -open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR. CONCLUSIONS MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.
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Affiliation(s)
- Fangling Shi
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shiyuan Wu
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Cai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Youming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China.
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Prospective randomized clinical trial of open operative, minimally invasive and conservative treatments of acute Achilles tendon tear. Arch Orthop Trauma Surg 2021; 141:751-760. [PMID: 32367375 DOI: 10.1007/s00402-020-03461-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The acute Achilles tendon rupture (AATR) is a common injury of great importance in an increasingly active society. When early functional treatment is established, recent literature shows comparable rates of re-rupture in conservative and surgical treatments of AATR. However, there is no study comparing the outcome using a dynamometer. The aim of this study is to evaluate the results of patients with AATR treated conservatively and surgically using a dynamometer. In addition, the data are compared to evaluation of the Achilles tendon with ultrasound. MATERIALS AND METHODS Between 2012 and 2015, 90 patients (mean age 41 years, male-to-female ratio 81:9) with AATR were enrolled in a prospective, randomized, and monocentric study. Thirty patients were assigned to each of the three different treatment groups. Group OPEN received a conventional open suture of the Achilles tendon, group MIN received a minimally invasive suture and patients in group CONS were treated conservatively. Follow-up treatment was the same for all patients regardless of the group they were assigned to. Plantar flexion force was assessed using a dynamometer (Biodex® System 3 Pro, Biodex Medical Systems). Further evaluation included a physical test and ultrasound of the Achilles tendon. RESULTS Sixty-nine patients were available for a 24-month follow-up. In each of the OPEN and MIN groups, there was one re-rupture. In the CONS group, there were two re-ruptures. A positive correlation between the Biodex® dynamometer measurement and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS-AH) could be found in all groups. Nevertheless, there were no significant differences between the treatment groups after 2 years. On sonography, all patients showed isolated structure loosening and a significantly thickened cross-sectional area compared with the non-injured opposite side, without differences between the groups. There was no correlation between the Biodex® measurement and sonographic outcome. CONCLUSION At 24-month follow-up, no significant difference can be found in patients with AATR treated operatively or conservatively. It is, therefore, important to inform patients with AATR regarding the respective advantages and disadvantages of the individual treatment strategies. LEVEL OF EVIDENCE Randomized controlled trial; level 1.
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Yang YP, Chen HY, Cui GQ, Xiu XL, Liu XP, An H, Ao YF. Endoscopic Surgery for Delayed Wound Healing After Achilles Tendon Suture Repair: A Report of Three Cases. Orthop Surg 2021; 13:1126-1131. [PMID: 33829676 PMCID: PMC8126896 DOI: 10.1111/os.12995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/30/2021] [Accepted: 02/21/2021] [Indexed: 11/30/2022] Open
Abstract
Background Delayed wound healing is a potention complication after Achilles tendon suture repair and occurs for various reasons. The conventional treatment for delayed wound healing is open surgery, but patients face long recovery times and postoperative care is difficult. Case Presentation This report presents three patients who were seen at our institute from April 2008 to October 2017 due to long‐term non‐healing wounds after surgery. All three patients had undergone surgery at least 2 months previously. We performed endoscopic surgery on these patients. After the operation, patients received less antibiotics and simpler care than would be required for conventional open surgery. There is no need to keep the wound open after the operation or perform wound cleaning for multiple times at the same time, which can reduce healing time. At the last follow up, all postoperative scores among the patients were significantly improved compared to before surgery. The Achilles tendon total rupture scores were excellent and the American Orthopedic Foot and Ankle Society scores were satisfactory, indicating improvements in Achilles tendon function and movement in patients after surgery. Conclusion Our case reports demonstrate that arthroscopic treatment for delayed wound healing after Achilles tendon suture repair is satisfactory and reliable; frequent opening of the wound for cleaning is not required after the operation, thus reducing the healing time.
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Affiliation(s)
- Yu-Ping Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China.,Department of Sports Medicine, Peking University Third Hospital-Chongli, Zhangjiakou city, Hebei province, 076350, China
| | - Hong-Yu Chen
- School of Clinical Medicine, Peking University of Medical Department, Beijing, China
| | - Guo-Qing Cui
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Xiao-Lei Xiu
- Department of Hand Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, China
| | - Xiao-Peng Liu
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Hua An
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Ying-Fang Ao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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Abstract
There is an ever-evolving debate about the best treatment option for Achilles tendon ruptures. There was a relative consensus that operative treatment yielded the best outcomes. Much of this is based on results in athletic populations. Conservative treatment was considered only for the elderly and those with very inactive lifestyles. There has been an evolution, however, with more surgeons utilizing an aggressive functional rehabilitation with conservative management. Surgical intervention still is the treatment of choice for elite-level athletes. The treatment of choice for patient populations other than elite athletes remains an individual choice between patient and physician.
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Frosch S, Buchhorn G, Hawellek T, Walde TA, Lehmann W, Hubert J. Comparison of the double loop knot stitch and Kessler stitch for Achilles tendon repair: A biomechanical cadaver study. PLoS One 2020; 15:e0243306. [PMID: 33270745 PMCID: PMC7714161 DOI: 10.1371/journal.pone.0243306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/18/2020] [Indexed: 12/28/2022] Open
Abstract
Tendon elongation after Achilles tendon (AT) repair is associated with the clinical outcome. Reliable suture techniques are essential to reduce gap formations and to allow early mobilization. Cyclic loading conditions represent the repetitive loading in rehabilitation. The aim of this study was to compare the Kessler stitch and double loop knot stitch (DLKS) in a cyclic loading program focussing on gap formation. Sixteen human cadaveric ATs were transected and sutured using either the Kessler stitch or DLKS (eight matched pairs). The suture-tendon configurations were subjected to cyclic loading and additional ultimate load to failure testing using the Zwick 1446 universal testing machine. Each AT survived cyclic loading, with a mean gap formation less than 5 mm after 1000 cycles. The mechanical properties of the Kessler stitch and DLKS were not significantly different after cyclic loading with a mean displacement of 4.57 mm (± 1.16) for the Kessler stitch and 4.85 mm (± 1.14) for the DLKS (P = .76). There were no significant differences in the ultimate load testing (P = .85). Both bioprotective techniques prevent excessive gaping in cyclic testing when tendon loading is moderate. Our data and those from literature of gap formation in cyclic and ultimate loading allow the conclusion, that early aggressive AT loading after repair (e.g. full weightbearing) overstrain simple as well as complex suture configurations. Initial intraoperative tightening of the knots (preloading) before locking is important to decrease postoperative elongation.
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Affiliation(s)
- Stephan Frosch
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Goettingen, Göttingen, Germany
- * E-mail:
| | - Gottfried Buchhorn
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Goettingen, Göttingen, Germany
| | - Thelonius Hawellek
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Goettingen, Göttingen, Germany
| | - Tim Alexander Walde
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Goettingen, Göttingen, Germany
| | - Wolfgang Lehmann
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Goettingen, Göttingen, Germany
| | - Jan Hubert
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
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.
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TÜZÜN HY, ERŞEN Ö, TÜRKKAN S, ARSENİSHVİLİ A, KÜRKLÜ M. Perkütan Aşil tendon rüptürü tamiri: güvenli ve güvenilir mi? EGE TIP DERGISI 2020. [DOI: 10.19161/etd.790413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Westin O, Sjögren T, Svedman S, Horvath A, Hamrin Senorski E, Samuelsson K, Ackermann P. Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis. BMC Musculoskelet Disord 2020; 21:358. [PMID: 32513228 PMCID: PMC7282056 DOI: 10.1186/s12891-020-03320-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments. METHODS Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments. RESULTS A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically. CONCLUSION The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Tony Sjögren
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Svedman
- Integrative Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Horvath
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Paul Ackermann
- Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Claus LE, Humbyrd CJ. Ethics in the Setting of Clinical Equipoise: Achilles Tendon Rupture in a Patient with Obesity. J Bone Joint Surg Am 2019; 101:e89. [PMID: 31483409 DOI: 10.2106/jbjs.19.00144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Lauren Elizabeth Claus
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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