Novel approach to repair of acute achilles tendon rupture: early recovery without postoperative fixation or orthosis

Immediate mobilization after repair of Achilles tendon rupture may increase the incidence of re-rupture: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Achilles tendon rupture (ATR) is a significant injury that can require surgery and can have the risk of re-rupture even after successful treatment. Consequently, to minimize this risk, it is important to have a thorough understanding of the rehabilitation protocol and the impact of different rehabilitation approaches on preventing re-rupture.

MATERIALS AND METHODS

Two independent team members searched several databases (PubMed, EMBASE, Web of Science, Cochrane Library, and CINAHL) to identify randomized controlled trials (RCTs) on operative treatment of ATR. We included articles that covered open or minimally invasive surgery for ATR, with a detailed rehabilitation protocol and reports of re-rupture. The study protocol has been registered at PROSPERO and has been reported in the line with PRISMA Guidelines, Supplemental Digital Content 1, http://links.lww.com/JS9/C85, Supplemental Digital Content 2, http://links.lww.com/JS9/C86 and assessed using AMSTAR Tool, Supplemental Digital Content 3, http://links.lww.com/JS9/C87.

RESULTS

A total of 43 RCTs were eligible for the meta-analysis, encompassing a combined cohort of 2553 patients. Overall, the postoperative incidence of ATR patients developing re-rupture was 3.15% (95% CI: 2.26-4.17; I2=44.48%). Early immobilization group patients who had ATR had a 4.07% (95% CI: 1.76-7.27; I2=51.20%) postoperative incidence of re-rupture; Early immobilization + active range of motion (AROM) group had an incidence of 5.95% (95% CI: 2.91-9.99; I2=0.00%); Early immobilization + weight-bearing group had an incidence of 3.49% (95% CI: 1.96-5.43; I2=20.06%); Early weight-bearing + AROM group had an incidence of 3.61% (95% CI: 1.00-7.73; I2= 64.60%); Accelerated rehabilitation (immobilization) group had an incidence of 2.18% (95% CI: 1.11-3.59; I2=21.56%); Accelerated rehabilitation (non-immobilization) group had a rate of 1.36% (95% CI: 0.12-3.90; I2=0.00%). Additionally, patients in the immediate AROM group had a postoperative re-rupture incidence of 3.92% (95% CI: 1.76-6.89; I2=33.24%); Non-immediate AROM group had an incidence of 2.45% (95% CI: 1.25-4.03; I2=22.09%).

CONCLUSIONS

This meta-analysis suggests the use of accelerated rehabilitation intervention in early postoperative rehabilitation of the Achilles tendon. However, for early ankle joint mobilization, it is recommended to apply after one to two weeks of immobilization.

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

Chronic Achilles tendon rupture in elderly treated with a combination of the side-locking loop suture technique and early rehabilitation protocol: two cases report

A chronic Achilles tendon rupture (ATR) is generally defined as a rupture that occurs more than 4-6 weeks after the initial injury. A variety of corrective techniques have been reported, such as direct repair, V-Y plasty, turndown flap, tendon transfer and free tendon grafting. These procedures generally produce good results, but have the disadvantage of requiring prolonged immobilization and weight-bearing restrictions. This may be a risk factor for falls and decreased function in the lower limbs, especially in older patients. Side-locking loop sutures (SLLS) were first introduced in 2010 as a direct repair technique for acute ATR. This technique provides higher tensile strength, which may allow for early rehabilitation protocols such as early range of motion and early weight-bearing of the ankle without postoperative immobilization. In this report, we describe two cases of chronic ATR in elderly patients treated with SLLS and an early rehabilitation protocol.

ACFAS Clinical Consensus Statement: Acute Achilles Tendon Pathology

Injuries to the Achilles tendon are a challenge to the foot and ankle surgeon. In recent years, research has led to a relative change in the way that many surgeons view acute Achilles tendon rupture. In an effort to fully evaluate these trends, as well as to evaluate all aspects of care for acute Achilles tendon rupture, the American College of Foot and Ankle Surgeons convened a panel of experts to create a clinical consensus statement to address selected aspects of care of the acute Achilles tendon injury.

Duration of immobilisation after Achilles tendon rupture repair by open surgery: a retrospective cohort study

Background

The best treatment for acute Achilles tendon ruptures remains controversial. No cohort studies have compared different immobilisation durations after open surgery. This retrospective cohort study aimed to determine the optimal duration of immobilisation after this surgery.

Methods

A total of 266 patients with acute Achilles tendon rupture were divided into 4 groups (A, B, C, and D) according to immobilisation duration of 0, 2, 4, and 6 weeks, respectively. All patients underwent the same suture technique with a similar rehabilitation protocol and were examined clinically at 2, 4, 6, 8, 10, 12, 14, 16, 24, and 48 weeks, with a final follow-up at a mean of 22.3 months postoperatively. The primary outcome was the time of return to light sports activity (LSA). Secondary outcomes included range of motion (ROM) and single-legged heel rise height (SHRH). Data on operation time, complications, visual analogue pain scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Achilles tendon Total Rupture score (ATRS) were also collected. Demographic baseline data were analysed using one-way analysis of variance; outcome parameters were analysed using Kruskal-Wallis H test, and complications were analysed using Fisher’s exact test. Statistical significance was considered at P ≤ 0.05.

Results

VAS scores decreased significantly, reaching 0 in all groups after 12 weeks. The AOFAS and ATRS scores were significantly different between the groups from weeks 2 to 12 (P<0.001) and weeks 2 to 16 (P<0.001), respectively. All the mean scores showed better results in group B than in the other groups. In terms of recovery time of ROM, SHRH, and LSA, groups A and B were significantly faster than groups C and D (P<0.001). There were 13 (13/266, 4.9%) complications: 5 superficial infections, 3 deep venous thrombosis, and 5 trauma-related re-ruptures. On the last follow-up, all complications had recovered. There were no significant differences in complications between the groups.

Conclusions

Immobilisation for 2 weeks after this open surgery is the best choice for early rehabilitation and weight-bearing while minimising pain and other complications.

Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon

Background:

The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture.

Methods:

A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up.

Results:

Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up ( P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively ( P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery.

Conclusion:

The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery.

Level of Evidence:

Level IV, retrospective case series.

Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review

Background:

Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines.

Purpose:

To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture.

Results:

A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53).

Conclusion:

Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.

A novel method for reducing gap formation in tendon repair

Background

This study investigates gap formation in tendon repair using a novel tensioning method.

Hypothesis

The novel stitch will demonstrate less gap formation than the other suture configurations tested.

Methods

Porcine tendons stitched with classic Krackow stitch configurations were compared to a Krackow stitch modified with a proximal Tension-Assist Loop. Each group was cyclically loaded followed by analysis of the tendon-suture construct for gap formation.

Results

The Tension-Assist Loop group produced significantly less gap formation than each of the other stitch groups.

Conclusion

Decreasing early gap formation may be beneficial in allowing early rehabilitation and range of motion.

Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair

PURPOSE

Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair.

METHODS

A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included.

RESULTS

One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment.

CONCLUSION

Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician.

LEVEL OF EVIDENCE

II.

[Biomechanical study of different suture methods in repairing tendon rupture]

Objective

To evaluate the biomechanical property of tendons repaired with the modified Kessler suture combined with " 8" suture, and to provide evidence for the clinical application of this suture methods in repairing acute Achilles tendon rupture.

Methods

Forty frozen flexor digitorum longus tendons from fresh pork hind leg were randomly assigned into 4 groups, 10 specimens each group. In group A, the tendons were dissected transversely at the midpoint to forming the model of tendon with transversely cutting injury. The tendons in groups B, C, and D were dissected transversely at the midpoint, then a 2 cm segment of tendon from the incision in each side was dissected longitudinally with 1 mm internal to forming " frayed tendon" model. All the tendons were sutured with2-0 non-absorbable suture material with different suturing methods: in group A, the tendons with transversely cutting injury model with Krackow suture, and in the groups B, C, and D with Krackow suture, Kessler suture, and the modified Kessler suture combined with " 8" suture separately. All repaired tendons were fixed onto the biomechanical testing machine. The length, width, and thickness of each side and midpoint of the tendons were recorded, and the cross-sectional area was calculated. The tendons were stretched at a speed of 15 mm/minutes until failure (suture avulsion or rupture). The computer automatically recorded the maximum load, stress, strain, the failure displacement, and the stiffness. These biomechanical parameters of tendons in different groups were analyzed and compared.

Results

There was no significant difference in the length and cross-sectional area of each tendon among 4 groups ( F=0.245, P=0.863; F=0.094, P=0.963). Two tendons in group B, 1 in group C, and 1 in group D were excluded because of tendon slipping; all tendons in group A and 8 tendons in group B failured due to suture rupture, 9 tendons in group C due to suture slipping, and 9 tendons in group D due to 3 sutures slipping from tendon tissue together. The maximum load, the maximum stress, the maximum strain, the failure displacement, and the stiffness of the tendons between groups A and B showed no significant difference ( P>0.05). The maximum load, the maximum stress, and the stiffness of the tendons in group D were larger than those in both groups B and C ( P<0.05), but no significant difference was found in the maximum strain and the failure displacement between groups B, C, and D ( P>0.05). The maximum load, the maximum stress, the failure displacement, and the stiffness of the tendons in group B were larger than those in group C ( P<0.05), but the difference of maximum strain between groups B and C was not significant ( P>0.05).

Conclusion

The modified Kessler suture combined with " 8" suture can provide better biomechanical property of the repaired tendon compared with other suture approaches.

Efficacy of repair techniques of the Achilles tendon: A meta-analysis of human cadaveric biomechanical studies

PURPOSE

Achilles injuries are very common, mainly among young athletes. When indicated, the surgical treatment aims for strong repairs that can resist distraction and consequently ruptures. The majority of the published clinical meta-analyses reported comparisons between broad treatment modalities such as conservative treatment, open, and minimally invasive surgery.

METHODS

A meta-analysis has been conducted to assess further clinical and biomechanical variables on human cadavers related to the efficacy of Achilles repair. A total of 26 studies with 596 legs met the inclusion criteria. The maximal load to failure was set as the primary outcome. Eleven studies were amenable to meta-analysis.

RESULTS

In the reinsertion group, the analysis of the single row vs. double row subgroup showed a significantly higher strength for the latter (1.27, 95% CI=0.748-1.806, I²=81%, P<0.0001). In the mid-tendon repair group, the Achillon vs. Krackow sutures and the Bunnell vs. Krackow sutures subgroups showed no difference while the Bunnell and Krakow sutures were significantly stronger than the Kessler sutures (0.96, 95% CI=0.510-1.405, I²=63.3%, P<0.0001 and 1.37, 95% CI=2.286-0.468, I²=83.4%, P=0.003; respectively).

CONCLUSIONS

The assessment of heterogeneity located variables such as age, suture/material type, number of strands, type of testing machine and software, preloading, ankle position and loading type as potential confounders. The results of this meta-analysis are likely to have a significant impact in clinical practice.

Acute Achilles Tendon Rupture Treated by Double Side-Locking Loop Suture Technique With Early Rehabilitation

BACKGROUND

Although early accelerated rehabilitation is recommended for the treatment of acute Achilles tendon rupture, most traditional rehabilitation techniques require some type of brace.

METHODS

We retrospectively analyzed 44 feet of 44 patients (25 male and 19 female) with a mean age of 31.8 years who had an acute Achilles tendon rupture related to athletic activity. Patients had been treated by a double side-locking loop suture (SLLS) technique using double antislip knots between stumps and had undergone early accelerated rehabilitation, including active and passive range of motion exercises on the day following the operation and full weight-bearing at 4 weeks. No brace was applied postoperatively. The evaluation criteria included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS) score; active plantar flexion and dorsiflexion angles; and the intervals between surgery and the time when patients could walk normally without any support, perform double-leg heel raises, and perform 20 continuous single-leg heel raises of the operated foot.

RESULTS

Despite postoperative early accelerated rehabilitation, the AOFAS score and active dorsiflexion angles improved over time (6, 12, and 24 weeks and 2 years). A mean of 4.3 ± 0.6 weeks was required for patients to be able to walk normally without any support. The mean period to perform double-leg heel raises and 20 continuous single-leg heel raises of the injured foot was 8.0 ± 1.3 weeks and 10.9 ± 2.1 weeks, respectively. All patients, except one who was engaged in classical ballet, could return to their preinjury level of athletic activities, and the interval between operation and return to athletic activities was 17.1 ± 3.7 weeks.

CONCLUSION

The double SLLS technique with double antislip knots between stumps adjusted the tension of the sutured Achilles tendon at the ideal ankle position and provided good clinical outcomes following accelerated rehabilitation after surgery without the use of a brace.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Outcome of a one-stage tensile stress surgical technique and early postoperative rehabilitation in the treatment of neglected achilles tendon rupture

The present study evaluated the effect of single-stage internal traction combined with early postoperative active rehabilitation and the yurt bone suture method, a new surgical technique, on the clinical outcomes after surgical repair of Achilles tendon. A total of 51 patients with neglected Achilles tendon rupture who underwent the yurt bone suture treatment also participated in an accelerated postoperative rehabilitation program. The clinical outcome was evaluated for 18 weeks using the Leppilahti scoring system, bilateral ultrasound examination, and computed tomography examination. The ultrasound and computed tomography examinations revealed that Achilles tendon elongation and adhesion occurred in none of the patients. All the patients could perform the single leg heel raise exercise for a mean of 30 ± 7.6 seconds at 12 weeks postoperatively. In addition, the patients could participate in sport exercises and heavy physical activities by around 13 weeks postoperatively. The mean Leppilahti score was 85.8 ± 3.7 at 8 weeks postoperatively, and it had increased to 96.1 ± 3.2 and 100.0 ± 0.0 at 12 and 18 weeks, respectively, after the operation. The 1-stage internal traction technique, combined with early postoperative active rehabilitation and the yurt bone surgical technique, resulted in good clinical outcomes for the treatment of neglected Achilles tendon rupture.

Biomechanical comparison of Krackow locking stitch versus nonlocking loop stitch with varying number of throws

BACKGROUND

Common suture configuration techniques used for ligament and tendon grafts and repair are the Krackow locking stitch and a nonlocking loop stitch, such as a whipstitch. Clinically, the preferences of orthopaedic surgeons vary.

HYPOTHESIS

The Krackow locking stitch and the nonlocking whipstitch, with varying suture loops, produce different biomechanical and physical effects on the tendon end.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 52 fresh-frozen porcine flexor digitorum tendons were used and assigned into 10 groups. Two stitch configurations (Krackow stitch [K] and whipstitch [W]) with varying number of loops (2 throws, n = 6; 4 throws, n = 5; 6 throws, n = 5; 8 throws, n = 5; 10 throws, n = 5) were tested. No. 2 FiberWire was used. Each sample was preloaded to 5 N and then cyclically loaded for 200 cycles to 200 N at 1 Hz, and then the tendon-suture construct was analyzed for gap formation, tendon elongation, and tendon end width. Next, each tendon was loaded to failure, and ultimate strength and mode of failure were recorded. Data were evaluated with 2-way analysis of variance.

RESULTS

For gap formation, the Krackow stitch produced less gap compared with the whipstitch (15.2 ± 4.0 mm [K] vs 18.9 ± 6.8 mm [W]; P = .012). Gap formation was larger when the number of loops increased from 2 to ≥6 (P = .015). For elongation, the Krackow technique increased the tendon length after cyclic loading. In contrast, the whipstitch was noted to shorten the length of the tendon (1.17 ± 0.97 mm [K] vs -0.14 ± 1.13 mm [W]; P < .001). For tendon end width, the Krackow better preserved the transverse width (-0.64 ± 0.81 mm [K] vs -1.39 ± 0.64 mm [W]; P = .001). Both stitch types had similar ultimate strength (322.1 ± 20.3 N [K] vs 319.7 ± 20.4 N [W]; P = .676) and modes of failure (all by suture breakage; therefore, no statistical calculation was performed). There was no statistical difference in tendon elongation, width, failure load, or mode regardless of the number of throws.

CONCLUSION/CLINICAL RELEVANCE

Given the finding that the Krackow suture had less gap formation and better preservation of tendon architecture (length and width) compared with the whipstitch, coupled with the finding that ultimate strength is similar with both types of sutures, the Krackow stitch is recommended for tendon reconstruction when these parameters are important.

Biomechanical Study of Two Peripheral Suture Methods on Repaired Tendons

Flexor digitorum tendon injuries are challenging conditions to manage to ensure optimal patient outcomes. While several surgical approaches with high success rates have been developed, there remains no gold standard for suture technique for the repair of flexor tendon injuries. In this study, we compared two distinct peripheral suture methods on the strength of repaired tendons. Pig flexor digitorum profundus tendons were used in biomechanical studies and the biomechanical influence on tendon repair of continuous running peripheral suture (CRPS) and continuous locking peripheral suture (CLPS), were compared, using stitch length ranging from 1mm to 5mm. In CRPS, the 1mm stitch length group displayed the highest maximum load and breaking power, which was 1.57 fold higher than the 2mm stitch length group. Pairwise comparison revealed that the 1 and 2mm groups were statistically different from the 3, 4, and 5mm stitch length groups while comparison among the latter groups was not statistically significant. For CLPS, the 1mm group exhibited consistently the highest maximum load strength and breaking power, which was twice the strength displayed by the 2mm group. Pairwise comparisons between groups showed statistical significance. For future repairs of flexor tendon injuries, 1mm stitch length is highly recommended for simple peripheral suture.

Randomized controlled trial of accelerated rehabilitation versus standard protocol following surgical repair of ruptured Achilles tendon

BACKGROUND

There is no consensus regarding the optimal management of the acutely ruptured Achilles tendon (TA). Functional bracing alone achieves outcomes similar to those of surgical repair. Surgical repair combined with immediate mobilization may improve the clinical outcome further. The purpose of our study was to determine if an accelerated rehabilitation programme following surgical repair of the ruptured TA could improve clinical outcome, relative to the standard protocol.

METHODS

Patients with an acutely ruptured TA were randomly allocated to undergo an accelerated programme (AP) or standard programme (SP), following surgery. Outcome was assessed at 12 months post-surgery using the Achilles tendon Total Rupture Score (ATRS), the heel-raise height and the time taken to return to running.

RESULTS

Fifty-one patients completed the study, 25 in the AP group and 26 in the SP group. At 12 months post-surgery, the ATRS results were similar in the two treatment groups (87.46 in AP with standard error (SE) of 0.735 versus 87.12 in SP with SE of 0.75) while the AP group had less lengthening of the TA (0.385 cm, SE 0.166 versus 1.00 cm, SE 0.169) and a more rapid return to running (17.231 weeks, SE 0.401 versus 21.08 weeks, SE 0.409), than the SP group.

CONCLUSION

The accelerated rehabilitation programme resulted in less tendon lengthening, more rapid return to running, but similar ATRS relative to the standard rehabilitation. Immobilization following TA repair may prolong recovery.

Active Achilles tendon kinesitherapy accelerates Achilles tendon repair by promoting neurite regeneration

Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7–21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy.

Unrecognized pediatric partial Achilles tendon injury followed by traumatic completion: a case report and literature review

Achilles tendon ruptures are a relatively common athletic injury but are exceedingly rare in the pediatric population. We describe the case of a 10-year-old ice hockey player who experienced an Achilles tendon injury from a laceration to the posterior leg from a skate blade that led to a partial tendon laceration. This tendon injury was initially unrecognized despite an emergency department evaluation. The patient continued to complain of weakness and paresthesia after the skin laceration had healed. A traumatic dorsiflexion injury while running several weeks later led to a traumatic complete tendon rupture. The clinical, operative, and physical therapy records were reviewed to complete the history, treatment, and rehabilitation progress. The initial laceration injury had occurred 6 weeks before presentation, and the traumatic dorsiflexion injury had occurred 2 days before referral to an acute orthopedics clinic. Open repair was performed several days after the traumatic completion of the laceration, and the patient was immobilized in a cast for 5 weeks. The patient had weaned off crutches by 10 weeks postoperatively and had returned to some activities and light skating at 5.5 months. A full return to running and ice hockey had been achieved by 8 months postoperatively. The optimal repair for this injury has not been well established in published studies. We have concluded that laceration injuries have the potential to mask tendon injuries and that prolonged symptoms after a laceration should suggest occult pathologic features. Open tendon repair is a viable treatment option in the pediatric patient with Achilles tendon ruptures. A return to activities within a reasonable period can be expected with robust physical therapy.

A novel repair method for the treatment of acute Achilles tendon rupture with minimally invasive approach using button implant: a biomechanical study

BACKGROUND

Minimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low rate of complications. However there are still controversies about optimal technique. In this study we aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair technique and evaluate its biomechanical properties comparing with native tendon and Krackow technique.

METHODS

27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including native tendons. Unidirectional tensile loading to failure was performed at 25mm/min. Biomechanicalproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and Young'smodulus (GPa) was measured for each group. All groups were compared with each other using one-wayANOVA followed by the Tukey HSD multiple comparison test (a=0.05).

RESULTS

The average peak force (N) to failure of group 1 and group 2 and control group was 415.6±57.6, 268.1±65.2 and 704.5±85.8, respectively. There was no statistically significant difference between native tendon and group 1 for the amount elongation at failure (p>0.05).

CONCLUSIONS

Regarding the results, we concluded that Endobutton-assisted modified Bunnell technique provides stronger fixation than conventional techniques. It may allow early range of motion and can be easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality tendon at the distal part of rupture.

LEVEL OF EVIDENCE

Level II, Biomechanical research study.

Modification of side-locking loop suture technique using an antislip knot for repair of Achilles tendon rupture

The 2-strand side-locking loop suture technique provides high tensile strength and stiffness immediately after surgery, and good clinical results have been reported in the treatment of Achilles tendon rupture. However, it is assumed that major differences exist among surgeons with regard to the optimal tension of the side-locking loop suture. We report a detailed technique to ensure application of a standard tension with the use of the side-locking loop suture in the clinical setting.

Novel surgical technique and early kinesiotherapy for acute Achilles tendon rupture

BACKGROUND

This prospective study was performed to investigate the contribution of early kinesiotherapy, the active exercise and movement of the ankle and knee joints, following a novel surgical technique for reconstruction of the acutely ruptured Achilles tendon and the underlying mechanisms involved.

MATERIALS AND METHODS

One hundred and seven patients with an acute Achilles tendon rupture received postoperative early kinesiotherapy treatment following the novel ``Pa-bone'' surgical technique. Clinical outcomes were evaluated using the Achilles tendon rupture score, a score for measuring outcomes related to symptoms and physical activity, and bilateral ultrasonographic examination of the Achilles tendon.

RESULTS

Range-of-motion recovery equal to the intact side averaged 7~weeks. Double-legged heel rises and sustained single-leg heel rise exercises were possible at an average of 1~week and 60± 2 days, respectively. All patients could perform single-leg heel rise of the injured foot for 60± 23 seconds at an average of 12 weeks. No rerupture was observed. In addition, ultrasonographic examination revealed that the cross-sectional areas of the ruptured tendon were significantly larger than those of the healthy side. Overall reconstruction of the Achilles tendon was obtained for most of the patients.

CONCLUSION

Postoperative early kinesiotherapy treatment following Pa-bone surgical technique resulted in excellent clinical outcomes and contributed to the overall reconstruction of the Achilles tendon.

Biomechanical comparison of four methods of repair of the Achilles tendon

We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p <  0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot.

The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.

Achilles tendon healing in rats is improved by intermittent mechanical loading during the inflammatory phase

Tendons adapt to changes in mechanical loading, and numerous animal studies show that immobilization of a healing tendon is detrimental to the healing process. The present study addresses whether the effects of a few episodes of mechanical loading are different during different phases of healing. Fifty female rats underwent Achilles tendon transection, and their hind limbs were unloaded by tail suspension on the day after surgery. One group of 10 rats was taken down from suspension to run on a treadmill for 30 min/day, on days 2-5 after transection. They were euthanized on day 8. Another group underwent similar treadmill running on days 8-11 and was euthanized on day 14. Continuously unloaded groups were euthanized on days 8 and 14. Tendon specimens were then evaluated mechanically. The results showed that just four loading episodes increased the strength of the healing tendon. This was evident irrespective of the time point when loading was applied (early or late). The positive effect on early healing was unexpected, considering that the mechanical stimulation was applied during the inflammatory phase, when the calluses were small and fragile. A histological study of additional groups with early loading also showed some increased bleeding in the loaded calluses. Our results indicate that a short episodes of early loading may improve the outcome of tendon healing. This could be of interest to clinical practice.

Strong tendon repair using SLLS technique for traumatic disruption of tibialis anterior tendon and extensor hallucis longus tendon to enable early rehabilitation after surgery

Level of Evidence: V, Expert Opinion