Simple end-to-end suture versus augmented repair in acute Achilles tendon ruptures: a retrospective comparison in 98 patients

Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?"

Background

Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications.

Methods

A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted.

Results

There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94).

Conclusion

In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature.

Level of Evidence

Level IV.

Comparison between primary repair and augmented repair with gastrocnemius turn-down flap for acute Achilles tendon rupture: a retrospective study with minimum 2-year follow-up

BACKGROUND

To explore and compare the clinical outcomes in patients undergoing primary repair versus augmented repair with a gastrocnemius turn-down flap for acute Achilles tendon rupture.

METHODS

From 2012 to 2018, the clinical data of 113 patients with acute Achilles tendon rupture who were treated with primary repair or augmented repair with a gastrocnemius turn-down flap by the same surgeon were retrospectively reviewed. The patients' preoperative and postoperative scores on the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society Ankle⁃Hindfoot (AOFAS) score, the Victorian Institute of Sport Assessment⁃Achilles (VISA-A), the Achilles tendon total rupture score (ATRS), and the Tegner Activity Scale were examined and compared. The postoperative calf circumference was measured. A Biodex isokinetic dynamometer was used to evaluate the plantarflexion strength on both sides. The time to return to life and exercise as well as the strength deficits in both groups were recorded. Finally, the correlation analyses between patient characteristics and treatment details with clinical outcomes were conducted.

RESULTS

In total, 68 patients were included and completed the follow-up. The 42 and 26 patients who were treated with primary repair and augmented repair were assigned to group A and B, respectively. No serious postoperative complications were reported. No significant between-group differences in any outcomes were observed. It was found that female sex was correlated with poorer VISA-A score (P = 0.009), complete seal of paratenon was correlated with higher AOFAS score (P = 0.031), and short leg cast was correlated with higher ATRS score (P = 0.006).

CONCLUSIONS

Augmented repair with a gastrocnemius turn-down flap provided no advantage over primary repair for the treatment of acute Achilles tendon rupture. After surgical treatment, females tended to had poorer outcomes, while complete seal of paratenon and short leg cast contributed to better results.

LEVEL OF EVIDENCE

Cohort study; Level of evidence, 3.

Repair of acute Achilles tears with plantaris augmentation

PURPOSE

To determine the benefits associated with using the fanned out plantaris tendon as a membrane to cover and augment the acute Achilles tendon midportion end-to-end suture repair.

METHODS

Between 2014 and 2018, 31 (67.4%) patients had plantaris augmented reconstruction and 15 simple end-to-end suture. The clinician filled out the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale and the patient the Achilles tendon total rupture score (ATRS). Examination included clinical examination, limb symmetry index (LSI) using the heel rise test, and ultrasound determination of cross-sectional area (CSA).

RESULTS

80.4% were males, mean age 41 (SD 6.7, range 29-57), of which 82.6% were sports accidents. 39/46 were operated in less than two weeks from injury. 82.6% were available at the two year follow-up. Duration of surgery (62.3 min vs 58, p = 0.45), AOFAS (89.6 vs 88.4, p = 0.61 and 97.2 vs 96.8, p = 0.72), ATRS (86.3 vs 83.8, p = 0.33 and 95.6 vs 93.6, p = 0.12), LSI (60.8% vs 58.75, p = 0.24 and 80.5 vs 79, p = 0.29), CSA (3.39cm² vs 3.36, p = 0.82 and 2.57 vs 2.59, p = 0.87), return to sport (80% vs 57, p = 0.15 and 84.6 vs 85.7, p = 1.00), and complications at six months and two years were comparable between the two techniques.

CONCLUSION

Fanned out plantaris augmentation of acute Achilles tendon tears yields excellent and comparable clinical and ultrasonographic results to end-to-end suture at mid-term follow-up.

Modified Bunnell suture repair versus bundle-to-bundle suture repair for acute Achilles tendon rupture: a prospective comparative study of patients aged <45 years

BACKGROUND

This study aimed to compare the operative outcome of percutaneous repair (modified Bunnell suture technique) versus open repair (bundle-to-bundle suture technique) of acute Achilles tendon rupture.

METHODS

Seventy-two consecutive patients who underwent surgical treatment of Achilles tendon rupture were evaluated in this prospective study. Thirty-six patients were treated using the bundle-to-bundle suture technique (group A), and 36 patients were treated using the modified Bunnell suture technique (group B). All patients underwent functional examination comprising measurement of the calf muscle circumference and performance of the single-leg heel-rise test. The length and diameter of the Achilles tendon were compared between the injured and uninjured sides on magnetic resonance imaging. The number of single-leg heel rises (height > 5 cm) performed within 15 s was compared between the injured and uninjured sides. The ankle range of motion was also recorded. The Achilles tendon total rupture score (ATRS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, and visual analog scale (VAS) pain score were used to evaluate the clinical outcome at 12 months postoperatively.

RESULTS

A total of 61 patients were followed up. The mean follow-up duration did not significantly differ between group A (23.73 ± 2.81 months) and group B (22.61 ± 3.96 months). However, there were significant differences between groups in the heel-rise test (group A, 1.74 ± 0.96; group B, 2.37 ± 1.42) and length of the Achilles tendon (group A, 11.98 ± 1.64 cm; group B, 11.11 ± 1.74 cm). The calf circumference of the injured side was significantly larger in group A than in group B (p = 0.043). The cross-sectional diameter of the Achilles tendon was significantly smaller in group A than group B. At final follow-up, there were no significant differences between the two groups in the ATRS, AOFAS score, or VAS score. One patient in group A had delayed wound healing, which resolved in 40 days.

CONCLUSIONS

Patients with acute Achilles tendon rupture treated with open repair (bundle-to-bundle suture technique) achieved a better clinical outcome regarding the heel-rise test and calf circumference compared with those treated with percutaneous repair (modified Bunnell suture technique).

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000035229 , 8/4/2020, Retrospectively registered.

Achilles Tendon Reconstruction with Semitendinous Tendon Grafts Is Associated with a High Complication Rate

BACKGROUND

In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation.

METHODS

We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016.

RESULTS

During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22-180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient).

CONCLUSIONS

In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.

Augmented Versus Nonaugmented Repair of Acute Achilles Tendon Rupture: A Systematic Review and Meta-analysis

BACKGROUND

Although simple end-to-end repair of the Achilles tendon is common, many augmented repair protocols have been implemented for acute Achilles tendon rupture. However, whether augmented repair is better than nonaugmented repair of an acute Achilles tendon rupture is still unknown.

PURPOSE

To conduct a meta-analysis to determine whether augmented surgical repair of an acute Achilles tendon rupture improved subjective patient satisfaction without an increase in rerupture rates. Secondary outcomes assessed included infections, ankle range of motion, calf muscle strength, and minor complications.

STUDY DESIGN

Meta-analysis.

METHODS

A systematic literature search of peer-reviewed articles was conducted to identify all randomized controlled trials (RCTs) comparing augmented repair and nonaugmented repair for acute Achilles tendon rupture from January 1980 to August 2016 in the electronic databases of PubMed, Web of Science (SCI-E/SSCI/A&HCI), and EMBASE. The keywords (Achilles tendon rupture) AND (surg* OR operat* OR repair* OR augment* OR non-augment* OR end-to-end OR sutur*) were combined, and results were limited to human RCTs and controlled clinical trials published in the English language. Four RCTs involving 169 participants were eligible for inclusion; 83 participants were treated with augmented repair and 86 were treated with nonaugmented repair.

RESULTS

Augmented repair led to similar responses when compared with nonaugmented repair for acute Achilles tendon rupture (93% vs 90%, respectively; P = .53). The rerupture rates showed no significant difference for augmented versus nonaugmented repair (7.2% vs 9.3%, respectively; P = .69). No differences in superficial and deep infections occurred in augmented (7 infections) and nonaugmented (8 infections) repair groups during postoperative follow-up ( P = .89). The average incisional infection rate was 8.4% with augmented repair and 9.3% with nonaugmented repair. No significant differences in other complications were found between augmented (7.2%) and nonaugmented (8.1%) repair ( P = .80).

CONCLUSION

Augmented repair, when compared with nonaugmented repair, was not found to improve patient satisfaction or reduce rerupture rate or infection rate. These conclusions are based on 4 trials with small sample sizes, and larger randomized trials are required to confirm these results.

Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?

Background:

Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications.

Methods:

A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted.

Results:

There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected ( P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified—a significantly lower complication rate than that reported in the literature ( P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature ( P < .0001; CI 0.067-1.94).

Conclusion:

In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients’ overall recovery, a significantly lower rate of complications existed compared to that reported in the literature.

Level of Evidence:

Level IV.

Management of acute Achilles tendon rupture with tendon-bundle technique

Objective * These authors contributed equally to this work. To explore tendon-bundle technique for treating Achilles tendon rupture with no defects. Methods Patients with full unilateral Achilles tendon rupture with no defects were included. The Achilles tendon medial edge surgical repair approach was used, revealing horsetail-like rupture bundles. Tendon bundles were anatomically realigned and repaired end-to-end using 5-0 sutures. Patients were followed-up for 1 year, and assessed for differences between the repaired versus healthy limb. Results Out of 24 patients (18 male, 6 female; aged 19-56 years) at 1 year following surgery, mean American Orthopaedic Foot and Ankle Society score was 92.4 ± 5.9; mean differences between the surgically repaired versus contralateral side in dorsiflexion and plantarflexion angle were 3.5 ± 2.3° and 5.6 ± 3.2°, respectively; mean difference in calf circumference between the two sides was 0.9 ± 0.5 cm; and mean increase in Achilles tendon width versus the healthy side was 0.8 ± 0.2 cm. By 1 year post-surgery, there were no significant between-side differences in dorsiflexion and plantarflexion angle, or calf circumference. Conclusions Tendon-bundle surgery resulted in good ankle function restoration and low complication rates. Tendon-bundle surgery may reduce blood supply destruction and maximally preserve Achilles tendon length, and may be effective for treating Achilles tendon rupture with no defects.

Nerve guidance conduit with a hybrid structure of a PLGA microfibrous bundle wrapped in a micro/nanostructured membrane

Nerve repair in tissue engineering involves the precise construction of a scaffold to guide nerve cell regeneration in the desired direction. However, improvements are needed to facilitate the cell migration/growth rate of nerves in the center of a nerve conduit. In this paper, we propose a nerve guidance conduit with a hybrid structure comprising a microfibrous poly(lactic-co-glycolic acid) (PLGA) bundle wrapped in a micro/nanostructured PLGA membrane. We applied sequential fabrication processes, including photolithography, nano-electroforming, and polydimethylsiloxane casting to manufacture master molds for the repeated production of the PLGA subelements. After demolding it from the master molds, we rolled the microfibrous membrane into a bundle and then wrapped it in the micro/nanostructured membrane to form a nerve-guiding conduit. We used KT98/F1B-GFP cells to estimate the migration rate and guidance ability of the fabricated nerve conduit and found that both elements increased the migration rate 1.6-fold compared with a flat PLGA membrane. We also found that 90% of the cells in the hybrid nano/microstructured membrane grew in the direction of the designed patterns. After 3 days of culturing, the interior of the nerve conduit was filled with cells, and the microfiber bundle was also surrounded by cells. Our conduit cell culture results also demonstrate that the proposed micro/nanohybrid and microfibrous structures can retain their shapes. The proposed hybrid-structured conduit demonstrates a high capability for guiding nerve cells and promoting cell migration, and, as such, is feasible for use in clinical applications.

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

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

Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up

BACKGROUND

This prospective randomized trial with a mean fourteen-year follow-up compared simple end-to-end repair with fascial flap-augmented repair for acute Achilles tendon ruptures.

METHODS

From 1998 to 2001, sixty patients with acute Achilles tendon rupture were randomized to receive simple end-to-end repair or augmented repair; both groups were treated with postoperative bracing allowing free active plantar flexion. After a follow-up of thirteen years or more, fifty-five patients (twenty-eight in the nonaugmented-repair group and twenty-seven in the augmented-repair group) were reexamined. Outcome measures included the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey.

RESULTS

After a mean of fourteen years of follow-up, the mean Leppilahti score was 87.1 points for the nonaugmented repairs and 91.5 points for the augmented repairs, with a mean difference of 4.3 points (95% confidence interval [CI], -0.1 to 8.8 points). The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the nonaugmented repairs and 107.3 Nm after the augmented repairs (mean difference, 5.3 Nm [95% CI, -22.2 to 11.6 Nm]) and a median work-displacement deficit of 6.7% to 20.3% after the nonaugmented repairs and 12.8% to 18.0% after the augmented repairs (p = 0.9). Strength did not significantly change between the twelve-month and fourteen-year follow-up examinations. At a mean of fourteen years, the injured side showed a 12.2% to 18.0% median work-displacement deficit compared with the unaffected side (p < 0.001). RAND-36 scores indicated no between-group difference in health domains.

CONCLUSIONS

Augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair. Achilles tendon ruptures result in a permanent calf muscle strength deficit, but its clinical relevance remains unclear.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Is percutaneous suturing superior to open fibrin gluing in acute Achilles tendon rupture?

PURPOSE

Open fibrin gluing is reported to enable anatomical reconstruction with less soft tissue compromise than suture repair. Our main objective was to compare the complication rate, function, pain and disability of the two operative approaches of percutaneous suture using the Paessler technique and open fibrin gluing.

METHODS

Sixty-four patients (two centres, retrospective cohort study, 2000-2009) who had undergone acute Achilles tendon repair with either percutaneous suture (n = 27; 44 years) or open fibrin glue (n = 37; 45 years) took part in a follow-up examination after a median of 63 months (range, six to 180). Ankle range of motion, calf and ankle circumferences and return to work and sports activities were evaluated. Isokinetic und sonographic evaluation results were retrieved.

RESULTS

Complications were noted in 22 patients (34 %). Delayed wound healing without evidence of surgical site infection was found in three patients in the fibrin group and two patients in the suture group. Postoperative scar tenderness described as pain at the rim of the shoe was significantly more frequent in the suture group (p = 0.03). Re-rupture requiring re-operation occurred in one patient. Transient paresthesia of the heel occurred in 12 patients. No sural nerve lesions were reported. There was no significant difference between groups regarding lower leg circumference, disability, or function. Ultrasound and isokinetic measurements did not reveal a significant difference between the two methods.

CONCLUSIONS

The present study suggests that open fibrin gluing is a reasonable alternative to percutaneous repair of acute ruptures of the Achilles tendon and both techniques can yield reliably good results.

Long term results of acute Achilles repair with triple-bundle technique and early rehabilitation protocol

BACKGROUND

The best treatment for acute rupture of the Achilles tendon is still under debate. Our purpose was to evaluate surgical triple-bundle technique in selected patients with full subcutaneous rupture of Achilles tendon.

METHODS

Sixty-six consecutive patients (56 men, 10 women; age range 20-61 years) with full unilateral rupture of the Achilles tendon were surgically treated by the triple-bundle technique. Seventy-four percent of the lesions occurred during sport activity. Each patient was assessed by: (1) The American Orthopaedic Foot and Ankle Society (AOFAS) score; (2) the Leppilahti score; (3) the range of movement measurement of ankle joint; (4) ipsilateral thigh, calf, and ankle circumferences compared to the contralateral limb; (5) functional evaluation with isokinetic dynamometry of both limbs.

RESULTS

80.3% of the patients were fully satisfied (AOFAS ≥90) with treatment and resumed their previous level of sport. Concerning the outcomes, (1) the mean AOFAS score at 36 months was 93.9; (2) the mean Leppilahti score at 36 months was 91.8; (3) the mean difference in dorsiflexion and plantarflexion between the healthy side and the operated side was 4.3° and 6.9°, respectively. We observed calf muscle hypotrophy in two cases and scar complication in one. No re-ruptures occurred. Isokinetic tests performed 36 months after surgery showed a good restoration of plantarflexion. At univariate analysis AOFAS was influenced by age and difference between the healthy side and the operated side in dorsiflexion, plantarflexion, and circumference at all three levels and strenght at 60°/s. At univariate analysis, Leppilahti score confirmed the significant parameters of the AOFAS with the exception of age and difference of thigh circumference. The only predictive parameters in multivariate analysis were dorsiflexion difference (O.R. = 0.831; 95% C.I. 0.694-0.995; p = 0.044) and plantarflexion difference (O.R. = 0.777; 95% C.I. 0.631-0.958; p = 0.018).

CONCLUSION

In this case series the triple-bundle technique showed a low rate of complications and good functional restore tested with isokinetic tests. For these reasons afforded by biomechanical strength test reported in literature, this technique has to be considered a valid choice for the treatment of Achilles tendon rupture in young patients with a high level of sport activity.

Tendon-holding capacities of two newly designed implants for tendon repair: an experimental study on the flexor digitorum profundus tendon of sheep

Background:

Two main factors determine the strength of tendon repair; the tensile strength of material and the gripping capacity of a suture configuration. Different repair techniques and suture materials were developed to increase the strength of repairs but none of techniques and suture materials seem to provide enough tensile strength with safety margins for early active mobilization. In order to overcome this problem tendon suturing implants are being developed. We designed two different suturing implants. The aim of this study was to measure tendon-holding capacities of these implants biomechanically and to compare them with frequently used suture techniques

Materials and Methods:

In this study we used 64 sheep flexor digitorum profundus tendons. Four study groups were formed and each group had 16 tendons. We applied model 1 and model 2 implant to the first 2 groups and Bunnell and locking-loop techniques to the 3rd and 4th groups respectively by using 5 Ticron sutures.

Results:

In 13 tendons in group 1 and 15 tendons in group 2 and in all tendons in group 3 and 4, implants and sutures pulled out of the tendon in longitudinal axis at the point of maximum load. The mean tensile strengths were the largest in group 1 and smallest in group 3.

Conclusion:

In conclusion, the new stainless steel tendon suturing implants applied from outside the tendons using steel wires enable a biomechanically stronger repair with less tendon trauma when compared to previously developed tendon repair implants and the traditional suturing techniques.

Salvage technique for postoperative infection and necrosis of the Achilles tendon

Surgery of the Achilles tendon is associated with postoperative morbidity related to wound healing. Necrotic infection of the tendon is a rare but serious complication that may be associated with increasingly invasive surgical treatments using various free flap transfers proposed in the literature. Dealing with this complication, we prefer the technique of managed wound healing suggested by Dautry. The surgical procedure includes radical debridement of the infected tissue and necrotic Achilles tendon followed by managed wound healing with daily irrigation. Fifteen cases were treated between 1994 and 2003. Healing was achieved after 30 to 100 days. MRI results show scar tissue continuity suggesting a neotendon formation. Function was very satisfactory in 9/15 ankles. The salvage technique presented here for cases of infection and necrosis of the Achilles tendon is simple with low morbidity and results in effective wound and tendon healing with satisfactory functional and anatomical results.

A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture

Achilles tendon ruptures are a common injury afflicting predominantly the young male occasional sportsman. Previous studies have shown that outcome is better with surgical repair for the young active patient. There is no consensus as to whether there is a difference in outcome between open and percutaneous minimally invasive surgery (MIS). A meta-analysis was undertaken to compare the clinical outcomes of MIS with conventional open surgical repair. Six randomised controlled trials of 277 Achilles tendon repairs were eligible for review. This included 136 minimally invasive repairs and 141 conventional open repairs. On analysis, there was no significant difference between the two surgical approaches in respect to the incidence of re-rupture, tissue adhesion, sural nerve injury, deep infection and deep vein thrombosis (p>0.05). However, MIS had a significantly reduced risk of superficial wound infection, with three times greater patient satisfaction for good to excellent results compared with conventional open surgical approaches.

Augmented repair of acute tendo Achilles ruptures with gastrosoleus turn down flap

BACKGROUND

We present the results of primary repair of acute tendo Achilles (TA) rupture augmented with gastrosoleus turn down flap technique.

PATIENTS AND METHODS

78 consecutive patients with a complete acute rupture of the Achilles tendon operated between 1993 and 2004 were included in study. We performed a modification of the Lindholm technique in which the primary Kessler suture repair of the tendon was augmented by a turn-down ~3 cm × 10 cm gastrosoleus aponeurosis flap. In all cases, a short-leg circular walking cast was applied at 90° of the ankle dorsiflexion for 3 weeks and all the patients were encouraged to full weightbearing ambulation immediately. After removal of the cast, isometric and isokinetic ankle exercises were performed for 3 weeks. Modified Rupp Score was used to evaluate the subjective satisfaction.

RESULTS

All of patients returned to daily activity and 54 (69%) of them returned to previous sport activity. The tendon repair failed in two patients and they were reoperated with an allograft. Three patients developed infection and one of them required débridement. One developed deep venous thrombosis and two permanent sural nerve injuries were encountered. One of the patients had a severe skin necrosis, which was treated with rotation flap. The mean Rupp score was 29 (3-33).

CONCLUSION

Primary repair of acute tendo Achilles rupture augment with gastrosoleus turn down flip technique in combination of immediate weightbearing ambulation provides a good outcome, but is associated with similar complication rates to the previous literature.

Achilles tendon surgical revision with synthetic augmentation

In this paper we report about a 50-year-old patient who underwent a surgical revision procedure for rupture of the right Achilles tendon with the use of Ligastic((R)) synthetic graft in 1995, and in which a strong reactive immune response took place over the graft 11 years after. As far as we know, this is the first case described in literature of long-term follow-up inflammatory reaction after the use of such augmentation grafts in Achilles tendon repair.

Achilles tendon recurrent rupture following surgical repair: report on two cases

BACKGROUND

Rerupture is a main complication in Achilles tendon rupture surgery, with an incidence of 2-8%. Although wound break-down and rerupture are well known complications, spontaneous open rerupture has not been previously reported to the authors' knowledge.

METHODS

We report on two cases of open rerupture of Achilles tendon following augmented repair, through a transverse wound perpendicular to the primary incision line. Reruptures occurred 80 and 54 days after primary repair.

RESULTS AND CONCLUSIONS

After surgical repair long term follow-up results are good in both cases. This complication could be related to subtotal closure of the paratenon due to the bulk of the augmented repair and to an inadequate and a too extended period of postoperative ankle immobilization.

Treatment of acute Achilles tendon rupture: fibrin glue versus fibrin glue augmented with the plantaris longus tendon

In the surgical repair of Achilles tendon ruptures, suturing is standard, although fibrin glue also has been used for repair since the 1980s. Augmentation with the plantaris longus tendon is also a popular technique; however, no study has yet compared the outcome of augmented versus only glued repair of ruptured Achilles tendons. This study compares the long-term results of surgical repair of Achilles tendon rupture with fibrin glue versus fibrin glue augmented with the plantaris longus tendon. Forty patients who had undergone Achilles tendon repair with fibrin glue took part in a follow-up examination after an average of 11.5 years. The fibrin group consisted of 16 patients and the fibrin glue augmented with plantaris longus tendon group consisted of 15 patients. The modified Thermann score (adapted from Weber) and results of an isokinetic force measurement were the same in both groups, whereas complications in the 2 groups also did not differ. We conclude that augmentation with the plantaris longus tendon is not necessary when operatively treating acute ruptured Achilles tendons with fibrin glue.

LEVEL OF CLINICAL EVIDENCE

2.

Augmented compared with nonaugmented surgical repair of a fresh total Achilles tendon rupture. A prospective randomized study

BACKGROUND

Augmented and nonaugmented techniques have been used for the operative repair of a fresh complete Achilles tendon rupture. Augmented techniques have been favored for their stronger pullout strengths but have been avoided because of the risk of wound complications. If proven to be equally good, the nonaugmented technique would be the method of choice. In the present study, we hypothesized that augmentation with a down-turned gastrocnemius fascia flap would not provide better results than would end-to-end suture repair with use of the Krackow locking loop surgical technique.

METHODS

Sixty patients with an acute Achilles tendon rupture were randomized preoperatively to receive end-to-end suture repair with use of the Krackow locking loop technique either without augmentation (simple repair group) or with a down-turned gastrocnemius fascia flap as described by Silfverskiöld (augmented repair group). A brace allowed free active plantar flexion of the ankle postoperatively, whereas dorsiflexion was restricted to neutral for the first three weeks. Weight-bearing was limited for six weeks. The follow-up period was one year, and the patients were evaluated in terms of clinical measurements, an outcome score, isokinetic calf muscle performance tests, and tendon elongation measurements.

RESULTS

The mean operative time was twenty-five minutes longer and the incision was 7 cm longer in the augmented repair group as compared with the simple repair group (p < 0.001 for both). In the simple repair group, the overall ankle score was excellent for nineteen patients (63%) and good for eight patients (27%) and three patients (10%) had an early failure (all because of rerupture). In the augmented repair group, the ankle score was excellent for fourteen patients (56%) and good for six patients (24%) and five patients (20%) had a failure because of rerupture (three) or deep infection (two). The difference between the groups with regard to the overall result was not significant (p = 0.68). In the simple repair group the isokinetic calf muscle strength score was excellent for eleven patients (37%), good for fourteen patients (47%), and fair for two patients (7%), with three patients (10%) having a failure, whereas in the augmented repair group the score was excellent for nine patients (36%), good for seven patients (28%), fair for three patients (12%), and poor for one patient (4%), with five patients (20%) having an early failure. Achilles tendon elongation occurred in both groups, and elongation correlated significantly with isokinetic peak torque deficits (rho = 0.64, p = 0.001) and isometric strength deficits (rho = 0.48, p = 0.026) in the simple repair group. No significant differences were seen between the two groups at the three-month and twelve-month checkups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, overall outcome, isokinetic calf muscle strength, mean peak work-displacement relationships, or tendon elongation.

CONCLUSIONS

Augmented repair of a fresh total Achilles tendon rupture does not have any advantage over simple end-to-end repair.

Open versus minimal invasive repair with Achillon device

BACKGROUND

We prospectively analyzed and compared the functional and clinical results of patients with standard open and minimally invasive repair with the Achillon suture system at mid-term followup.

MATERIALS AND METHODS

From February 2004 to May 2007, 40 consecutive patients were operated for the treatment of acute Achilles tendon rupture with two different methods. None of the cases required adjunctive procedures like plantaris, flexor hallucis longus or gastrocnemius augmentation (Lindholm, Bosworth) to allow for acceptable end to end apposition. The patients were divided equally into two groups. In Group 1, only Krakow end-to-end suturing technique and in Group 2, Minimal invasive repair with Achillon suture system (Integra Life Sciences Corporation, Plainsboro, NJ) was used respectively. The average age of the patients was 40 years. Patients in study groups were followed up at mean of 22.4 (range, 10 to 48) months after surgery. At the end of the followup time, functional outcome scores and complications were evaluated.

RESULTS

The AOFAS hindfoot clinical outcome scores were 98.7 in Group 1, 96.8 in Group 2. Although there was a numerical increase in AOFAS Scores in Group 1, there was no significant difference. The surgical outcome concerning local tenderness, skin adhesions, scar and tendon thickness was better in Group 2 than in Group 1 with statistical significance.

CONCLUSION

Although functional outcomes of both treatment groups were the same, minimally invasive repair with the Achillon suture system provided safe, reliable and practical treatment with low risk of complications in the treatment of acute Achilles tendon ruptures.

Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture

The use of fibrin glue for repairing Achilles tendon ruptures was introduced in the 1980s. Although fibrin glue has been in regular use since that time, suturing remains the standard for surgical repair. Studies have indicated that, in the short term, fibrin glue is as effective as suturing. To date, there have been no long-term studies comparing the outcomes of these 2 techniques. This study compares the long-term results of surgical repair of Achilles tendon rupture with sutures versus fibrin glue. Forty-two patients who had undergone Achilles tendon repair with either suture or fibrin glue took part in a follow-up examination after an average of 12.1 years. The fibrin group consisted of 31 patients and the suture group consisted of 11 patients. Patients treated with fibrin glue reached a higher modified Thermann score (adapted from Weber), achieved equal results in an isokinetic force measurement, and showed fewer complications. The authors concluded that the use of fibrin glue for the repair of ruptured Achilles tendon is a suitable alternative to traditional sutures.

LEVEL OF CLINICAL EVIDENCE

2.

End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures

We prospectively analyzed the functional and clinical results of patients who underwent a single end-to-end suture and an augmented tendon repair with plantaris tendon at middle-term follow-up. From January 2003 to May 2005, 30 consecutive patients were operated on for the treatment of acute Achilles' tendon rupture by means of 2 different methods. No cases required adjunctive procedures to allow for acceptable end-to-end apposition. All ruptures were acute and repairable. The patients were divided into 2 groups. In group 1, augmentation with plantaris tendon was performed in addition to the Krakow end-to-end suturing technique in 16 patients, and in group 2, only the Krakow end-to-end suturing technique was used in 14 patients. The average age of the patients was 40.6 years. Patients in the study groups were followed up at a mean of 17.8 months after surgery. At the end of the follow-up, functional and subjective outcome scores were evaluated. The American Orthopaedic Foot and Ankle Society hindfoot clinical outcome scores were 96.7 in group 1 and 98.8 in group 2. Although there was a numerical increase in group 2, no significant difference was determined between the 2 study groups statistically. The surgical outcome concerning local tenderness, skin adhesion scar, and tendon thickness was better in group 2 than in group 1 without a statistical significance. Although functional outcomes of both treatment groups were the same, the end-to-end suturing technique provided a safer and more reliable treatment with a low risk of complications in the treatment of acute Achilles' tendon ruptures compared with the plantaris tendon augmentation technique.

Spiral-shaped metallic implant in the treatment of Achilles tendon ruptures: an experimental study on the Achilles tendon of sheep

There are 2 main factors contributing to the strength of tendon repair: the tensile strength of the material used in repair and the tendon-holding capacity of the suture configuration. In the current study, we aimed to find a technique with high repair strength by increasing both the tensile strength of the material and the tendon-holding capacity of the configuration. We developed metal implants (models 1 and 2) made from stainless-steel wire with 2 different spiral-shaped configurations. We measured tendon-holding capacities of these alternative implants biomechanically and compared them with frequently used suture techniques, the Bunnell and locking loop, which were achieved with 5 Ticron sutures. Sixty-four sheep Achilles' tendons were used in the study as 16 tendons in each group. Model 2 was more resistant to deformation under loading when compared with model 1. The results demonstrated that model 2 was superior to model 1 and both suture techniques. This study could be accepted as a step for reaching a strong tendon repair technique. It should be emphasized that the technique needs to be improved technically to make it convenient for clinical use.

Acute rupture of the Achilles tendon

Achilles tendon ruptures are common, and their incidence is increasing. The evidence for best management is controversial, and, in selected patients, conservative management and early mobilization achieves excellent results. Surgery is associated with an increased risk of superficial skin breakdown; however, modern techniques of percutaneous repair that are performed under local anesthesia and followed by early functional rehabilitation are becoming increasingly common, and should be considered when managing such patients.

Missed Achilles tendon rupture due to oral levofloxacin: surgical treatment and result

We describe a case of a 60-year-old male patient who was treated with oral levofloxacin. The patient sustained a total subcutaneous rupture of the left Achilles tendon which was not diagnosed for at least 5 months. Surgical treatment was successful.

Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia

Fifty-four consecutive acute Achilles tendon ruptures were treated with end-to-end suture augmented with gastrocnemius fascial flaps. Surgery was performed within 24 h. Mean patient age was 35 (23-57) years, and 46 were men. Mean follow-up time was 4.8 (2-8) years. At follow-up, the mean visual analogue scale for pain was 0.49, and the mean AOFAS ankle-hindfoot score was 95 (74-100) points. Fifty-three patients were able to stand on their tiptoes for 30 s and perform repeated toe raises, and 50 patients were able to perform single-limb hopping. Complications included rerupture in one case, deep infection in three cases, delayed wound healing in eight cases, and deep venous thrombosis in one case. Reconstruction of acute ruptures of the Achilles tendon augmented with gastrocnemius-soleus fascial flaps provided a good outcome but was associated with a high complication rate.