Minimally invasive reconstruction of chronic achilles tendon ruptures using the ipsilateral free semitendinosus tendon graft and interference screw fixation

[Treatment of chronic ruptures and defects of the Achilles tendon]

BACKGROUND

Achilles tendon ruptures that are older than 4-6 weeks or developed over a more extended period are chronic. Two challenges characterize the treatment. First, defect zones over a length of several centimeters must frequently be bridged. Second, a prolonged loss of function of the muscles leads to an irreversible fatty degeneration of the tissue. So that even if the tendon is restored, significant functional deficits remain. If there are doubts about the ability of the calf muscles to regenerate, regardless of the size of the defect, tendon transfers are recommended to use the power of an additional muscle to support the plantar flexion of the ankle.

TREATMENT

Established concepts are the transposition of the flexor hallucis longus or the peroneus brevis muscle. If the muscle is intact, defects of up to 2 cm can be treated with a direct suture. Defects between 2 and 5 cm can be bridged using a VY-plasty or a turndown flap. For larger defects, free tendon transplants can be considered. The technical alternative for larger defects is a tendon transfer of the flexor hallucis longus or the peroneus brevis muscle. Besides bridging the defect, another advantage of tendon transfer is that vital muscle tissue is placed in the bed of the Achilles tendon. Both tendons are covered with muscle tissue over nearly the full length, which offers advantages, especially in patients with critical soft tissue or after infection.

FOLLOW-UP TREATMENT AND PROGNOSIS

Follow-up treatment is analogous to an acute Achilles tendon rupture. However, permanent impairments are possible; 75-80% of athletes regain their original performance level.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

PURPOSE

After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport.

METHODS

The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias.

RESULTS

Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks.

CONCLUSION

In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function.

LEVEL OF EVIDENCE

Level IV.

Surgical Management of Chronic Achilles Tendon Ruptures: A Systematic Review and Proposed Treatment Algorithm

Background

As no evidence-based treatment guidelines exist for chronic Achilles tendon rupture (CATR), a systematic review of the literature was performed to compare the different treatment options and recommend a literature-based algorithm.

Methods

In June 2022, MEDLINE, Embase, and Cochrane Library databases were systematically reviewed based on the PRISMA guidelines. The level of evidence (LOE) and quality of evidence were evaluated, and statistics on clinical outcomes and complications were calculated.

Results

Twenty-seven studies with 614 patients were included. Three studies were LOE III and 25 studies were LOE IV. The mean Achilles tendon rupture score improved from a preoperative weighted mean of 38.8 ± 12.4 to a postoperative score 90.6 ± 4.7. The overall complication rate was 11.4%. Single techniques were used in 23 studies and dual techniques were used in 5 studies. The FHL tendon transfer was the most frequently used technique. We devised an algorithmic approach based on time from injury to surgical intervention and the length of the gap between the tendon stumps: >3 months: FHL transfer; <3 months (a) gap <2 cm, end-to-end repair; (b) gap 2 to 5 cm, gastrocnemius transfer, (c) gap >5 cm, semitendinosus autograft.

Conclusion

Surgical management of CATR produced improvements in patient-reported outcome scores at midterm follow up, but a high complication rate (11.4%) was noted. Our proposed treatment algorithm may assist in shared decision making for this complex problem.

Minimally invasive excision and reconstruction of Achilles tendon xanthoma using free autologous semitendinosus tendon transfer: a surgical technique

BACKGROUND

Tendon xanthomatosis is often associated with familial hypercholesterolemia, but it can also occur in other medical conditions. The Achilles tendon is the most common site of tendon xanthomas. Reconstruction of large defects after the xanthoma excision, can be challenging.

METHODS

We propose a novel technique for Achilles tendon reconstruction with the use of an ipsilateral autologous semitendinosus tendon graft. The technique consists of six steps.

RESULTS

This procedure has a low rate of complications and provides results that are at least comparable with those reported with other surgical approaches.

[Application of percutaneous transcalcaneal reconstruction technique for acute Achilles tendon insertion avulsion]

OBJECTIVE

To introduce a percutaneous transcalcaneal reconstruction technique for the treatment of acute Achilles tendon insertion avulsion, and to assess its short-term effectiveness.

METHODS

Between January 2014 and June 2020, 25 patients with acute Achilles tendon insertion avulsion were treated with the percutaneous transcalcaneal reconstruction technique. There were 24 males and 1 female, with an average age of 44.1 years (range, 34-60 years). The disease duration was 1-5 days (mean, 1.8 days). There were 23 cases of sports injury and 2 cases of fall injury. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 55.6±6.7 and the visual analogue scale (VAS) score was 4.6±0.5. The operation time, intraoperative blood loss, hospital stay, related complications, the time of weight-bearing standing with a slightly raised heel, and the time of walking with a slightly raised heel were recorded. The AOFAS ankle-hindfoot score and the VAS score were used to evaluate the ankle joint function and the pain. Achilles tendon continuity was examined by color Doppler ultrasonography and healing of the Achilles tendon was examined by MRI. At last follow-up, the Arner-Lindholm scale was used to evaluate the effectiveness.

RESULTS

The operation time was 45-50 minutes (mean, 46.8 minutes). The intraoperative blood loss was 10-20 mL (mean, 13.8 mL). The hospital stay was 4-6 days (mean, 4.9 days). The color Doppler ultrasonography before discharge showed the continuous recovery of the Achilles tendon. All incisions healed by first intention, and there was no complication such as sural nerve injury or deep venous thrombosis of lower extremity. All patients were followed up 15-50 months (mean, 30.3 months). After 14-21 days, the patients started to weight-bearing stand with a slightly raised heel, with an average of 17.6 days; they began to walk with a slightly raised heel at 20-28 days, with an average of 23.7 days. MRI showed that the Achilles tendon healed at last follow-up. The AOFAS score was 90.0±3.2 at 6 months after operation and 95.8±4.5 at last follow-up, and the VAS scores were 1.7±0.6 at 6 months and 1.0±0.8 at last follow-up, which were all improved when compared with those before operation (P<0.05); the difference was also significant between the two time points after operation (P<0.05). According to the Arner-Lindholm scale, the effectiveness at last follow-up was excellent in 25 cases. All patients had returned to sports.

CONCLUSION

The percutaneous transcalcaneal reconstruction technique is a promising alternative option in treating acute Achilles tendon insertion avulsion, for it can achieve early rehabilitation and better ankle function recovery.

Reconstruction of chronic tibialis anterior tendon ruptures using a free anterior half of a peroneus longus tendon autograft: A technical note

Purpose: Chronic rupture of the tibialis anterior (TA) tendon is rare. Several reconstruction techniques have been introduced. However, to the best of our knowledge, the use of a free anterior half of a peroneus longus tendon (AHPLT) autograft has not been reported for reconstruction of TA tendon rupture. This study aimed to describe the surgical technique and present the clinical outcomes of reconstruction of the chronic TA tendon ruptures using an AHPLT autograft. Methods: Between September 2013 and April 2019, five patients with chronic TA tendon rupture were surgically treated by reconstruction using an AHPLT autograft. The AHPLT could be easily harvested percutaneously with a tendon stripper from the ipsilateral lower leg around the reconstruction site. The study included four men and one woman, with a mean age of 43.8 (range: 23-65) years. Results: At a mean follow-up period of 42.8 (range; 12-70) months, the mean Foot Function Index value significantly improved from 53.6 ± 19.8 preoperatively to 25.8 ± 20.8 postoperatively (p = .04). None of the patients had morbidities (such as nerve injury, delayed tendon ruptures, or tenosynovitis) around the AHPLT donor site. Three patients were very satisfied, two patients were satisfied, and one patient was fair with the results. Conclusions: Reconstruction of chronic TA tendon ruptures using a free AHPLT autograft could be successfully performed with satisfactory clinical outcomes and minimal donor site morbidities. Future studies with a larger population size and a comparative group are warranted to confirm these findings.

Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques

PURPOSE

Achilles tendon ruptures are termed chronic after a delay in treatment for more than 4 weeks. The literature advocates surgical treatment with reconstruction to regain ankle push-off strength. The preferred technique is, however, still unknown and is often individualized. This study aims to present the technique and clinical outcome of an endoscopically assisted free semitendinosus reconstruction of chronic Achilles tendon rupture and Achilles tendon re-ruptures with delayed representation. It is hypothesized that the presented technique is a viable and safe alternative for distal Achilles tendon ruptures and ruptures with large tendon gaps.

METHOD

Twenty-two patients (13 males and 9 females) with a median (range) age of 64 (34-73) treated surgically with endoscopically assisted Achilles tendon reconstruction using a semitendinosus autograft were included. The patients were evaluated at 12 months post-operatively for Achilles tendon Total Rupture Score (ATRS), calf circumference, Achilles Tendon Resting Angle (ATRA), heel-rise height and repetitions together with tendon length determined by ultrasonography, concentric heel-rise power and heel-rise work.

RESULTS

The patients reported a median (range) ATRS of 76 (45-99) out of 100. The median (range) ATRA on the injured side was 60° (49°-75°) compared with 49.5° (40-61°), p < 0.001, on the non-injured side. Eighteen out of 22 patients were able to perform a single-leg heel-rise on the non-injured side. Sixteen patients out of those 18 (89%) were also able to perform a single heel-rise on the injured side. They did, however, perform significantly lower number of repetitions compared with the non-injured side with a median (range) heel-rise repetitions of 11 (2-22) compared with 26 (2-27), (p < 0.001), and a median (range) heel-rise height of 5.5 cm (1.0-11.0 cm) compared with 9.0 cm (5.0-11.5 cm), (p < 0.001). The median calf circumference was 1.5 cm smaller on the injured side, 37.5 cm compared with 39 cm, when medians were compared. The median (range) tendon length of the injured side was 24.8 cm (20-28.2 cm) compared with 22 cm (18.4-24.2 cm), (p < 0.001), on the non-injured side.

CONCLUSION

The study shows that endoscopically assisted reconstruction using a semitendinosus graft to treat chronic Achilles tendon ruptures and re-ruptures with delayed representation produces a satisfactory outcome. The technique can restore heel-rise height in patients with more distal ruptures or large tendon defects and is therefore a viable technique for Achilles tendon reconstruction.

LEVEL OF EVIDENCE

IV.

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.

Achilles Tendon Lesions - Part 2: Ruptures

The increasing incidence of calcaneal tendon ruptures has substantially impacted orthopedic care and costs related to its treatment and prevention. Primarily motivated by the increasing of life expectancy, the growing use of tenotoxic drugs and erratic access to physical activity, this injury accounts for considerable morbidity regardless of its outcome. In recent years, the evolution of surgical and rehabilitation techniques gave orthopedists better conditions to decide the most appropriate conduct in acute tendon rupture. Although still frequent due to their high neglect rate, Achilles chronic ruptures currently find simpler and more biological surgical options, being supported by a new specialty-focused paradigm.

Less Invasive Fixation of Acute Avulsions of the Achilles Tendon: A Technical Note

Purpose: Nowadays, surgical treatment of acute avulsions of the Achilles tendon represents a hard challenge. There is often the possibility that the calcaneus remains completely uncovered from the tendon, making the reinsertion of its distal stub complex. At the same time, the standard open surgical technique could cause difficult wound healing because of the weak blood supply, the increasing possibility of rupture, and the bacterial contamination. To overcome these risks, less invasive procedures should be considered. Methods: We developed an innovative minimally invasive procedure for fixation of acute avulsions of the Achilles tendon employing an integration of four longitudinal stab incisions and one distal semicircular Cincinnati incision. In this way, the distal Achilles tendon stub and the calcaneal insertion are exhibited. Results: We basted the tendon through percutaneous sutures performed across the four stab incisions with a Mayo needle threaded with Ultrabraid. The procedure is repeated with another loop of Ultrabraid. After having bruised the calcaneus bone insertion of the tendon, two sites for two suture anchors were prepared using a specific hole preparation device for the anchors’ footprint. Finally, we placed two suture anchors to reinsert the tendon to the calcaneal insertion. Conclusion: Our new less invasive technique is a promising alternative optional procedure for the Achilles tendon (AT) avulsion repair allowing clear exposure of the Achilles tendon insertion, maintaining the longitudinal wholeness of the dermis, and minimizing possible associated complications.

Epidemiology of Achilles tendon surgery in Italy: a nationwide registry study, from 2001 through 2015

Background

This study aims (1) to estimate the yearly number of Achilles tendon (AT) surgeries in Italy from 2001 to 2015 based on official hospitalization records; (2) to investigate the eventual presence of geographical variation in equity in access to AT surgery between three macroregions of Italy (North, Center and South); (3) to perform statistical projections of the number of AT procedure volumes and rates based on these data.

Methods

We analysed the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health for a 15-year period, from 2001 through 2015. These data are anonymous and include the patient’s age (evaluated in the class of age), sex, census region, the region of hospitalization, length of the hospitalization, public or private reimbursement and diagnosis.

Results

During the 15-year study period, 118,652 AT repair were performed in Italy, whose peak of incidence was in 2010. More than half of AT repairs was performed in the North of Italy (52.1%), while 27.2% was performed in the South of Italy and 20.6% Center of Italy. The projection model predicted a slight growth of 2.65% in 2025 in comparison with 2015.

Conclusion

The current study provides detailed information about the national population-weighted incidence of AT surgery, distribution and projection. The peak of average age was 35–45 year. The majority of AT procedures was performed in the North of Italy. The projection model predicts a slight growth of AT surgery by 2025. Furthermore, this 15-year nationwide registry study shows that the age of incidence of AT injuries shifted from 30 to 40 to 35–45 years compared to the available literature. The higher prevalence of AT surgery was found in men during the working age. Moreover, a low rate of procedures in pediatric and elder age classes was observed.

Higher Rate of Postoperative Complications in Delayed Achilles Tendon Repair Compared to Early Achilles Tendon Repair: A Meta-Analysis

BACKGROUND

Some authors found that delayed repair of Achilles tendon ruptures achieved similar functional outcomes when compared with acute repair of Achilles tendon ruptures. The purpose of our study was to compare functional outcomes and complication rates of acute repair to delayed repair after Achilles tendon ruptures.

METHODS

PubMed, Embase (Ovid) and the Cochrane Library were searched.

RESULTS

For Achilles tendon rupture score (ATRS), the overall result revealed that there was no significant difference in ATRS between acute repair groups and delayed repair groups (P = 0.59). For Tegner scores, Halasi scores and Achilles tendon resting angle (ATRA), there was no significant difference between the two groups (P = 0.28, P = 0.47 and P = 0.68). There was no significant difference in the subjective assessment between acute repair groups and delayed repair groups (P = 0.84). However, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.01). Subgroup analyses showed that the mean time from injury to surgery of delayed repair groups affect the pooled result substantially. For mean time less than 28d, there was no difference in the incidence of complications between acute repair groups and delayed repair groups (P = 0.09). However, for mean time more than 28d, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.05).

CONCLUSION

Our study showed delayed repair could obtain similar functional outcomes and subjective assessment when compared with acute repair. However, the rate of complications after delayed repair was higher than that of early repair. Further high-quality randomized controlled trials (RCT) are needed to evaluate the difference.

Chronic bilateral asynchronous achilles tendon rupture treated using modified whole flexor hallucis longus transfer reconstruction: A case report

INTRODUCTION

Achilles tendon rupture is common, but bilateral ruptures are very rare. Treatment of chronic Achilles tendon rupture is very challenging due tendon retraction and atrophied. We report a case of bilateral asynchronous Achilles tendon rupture patient who was treated with modified minimally invasive whole flexor hallucis longus (FHL) tendon transfer to repair the defects.

PATIENT CONCERNS

A 52-year-old male farmer presented to our hospital complaining of bilateral heel pain that had disrupted his walking for 6 months. The patient had been misdiagnosed and under-treated for 1 year. Physical examination showed that his plantar flexors were tender and weak, with marked hypotrophy of the calf muscles. Bilateral ankle radiographs of both X-ray and computed topography (CT) revealed no bone injure.

DIAGNOSIS

Magnetic resonance imaging (MRI) indicated a bilateral Achilles tendon rupture. The diagnosis was further confirmed by postoperative histological examination, which revealed Achilles tendonitis accompanied by regional calcification and chondrometaplasia.

INTERVENTIONS

Surgical reconstruction of the ruptured Achilles tendons was done through a modified minimally invasive whole FHL tendon transfer followed by physiotherapy.

OUTCOMES

The patient was immobilized in a cast for the next 6 weeks, gradual weight bearing gradually was then encouraged for another 6 weeks, and full weight-bearing started 3 months after surgery. By 6-month postoperation, the patient could walk and jog normally returned to his pre-injury working condition.

CONCLUSION

Surgical intervention is among the primary treatment of chronic Achilles tendon rupture. However, one of the challenges in its treatment is providing suitable graft for tendon reconstruction. Our case presents a successful reconstruction procedure using less-invasive whole FHL transfer technique. This surgical technique provides satisfactory clinical and functional outcome and can be considered for future therapy.

Reconstruction of Myerson type III chronic Achilles tendon ruptures using semitendinosus tendon and gracilis tendon autograft

BACKGROUND

Reconstruction of Myerson type III (defect size more than 5 cm) chronic Achilles tendon ruptures (CATRs) is a surgical challenge due to its large Achilles tendon defect. This study aims to describe our operative technique for Myerson type III CATR and its clinical outcomes.

PATIENTS AND METHODS

From May 2012 to April 2015, we treated seven patients (6 males, 1 female) with Myerson type III CATR using semitendinosus tendon and gracilis tendon autograft. The mean age was 47.3 years (range: 37-56). Patients were followed for a mean time of 31.3 months. All patients' defect size between Achilles ends after debridement was more than 5 cm and hence classified as Myerson type III. The clinical outcomes were evaluated by visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Achilles tendon total rupture score (ATRS), and the Short Form 36 (SF-36).

RESULTS

All patients reported good postoperative clinical outcomes. The average AOFAS score increased from 54.29 points (range: 46-65 points) preoperatively to 97.57 points (range: 90-100 points) at last follow-up. The average ATRS increased from 51.43 points (range: 40-61 points) preoperatively to 92.71 points (range: 83-100 points) at last follow-up. And the average VAS for pain was 0 at the last follow-up. The mean value of SF-36 physical increased from 32.14 points (range: 25-35 points) to 90 points (range: 80-95 points). And the mean value of SF-36 mental was improved from 37.14 points (range: 32-40 points) to 90.86 points (range: 84-96 points).

CONCLUSIONS

Semitendinosus tendon combined gracilis tendon autograft is a safe and effective technique in the reconstruction of Myerson type III CATR.

Quadriceps tendon autograft and platelet rich plasma injection to treat chronic Achilles tears-a minimum two-year follow-up

Background

The possibility of using a bone-tendon quadriceps tendon graft and platelet rich plasma (PRP) injection to enhance healing capability, to solve the defect created by stump retraction in chronic Achilles tendon ruptures was studied in a series of 8 patients.

Methods

A series of 8 patients studied prospectively and followed for more than 24 months is presented. Results were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, and evaluating pain, level of activity, footwear restrictions, and satisfaction. Statistical analysis was done by the sign test for matched pairs and Wilcoxon signed-rank test. Alpha error was set at 0.05.

Results

Preoperatively, patients showed an average AOFAS score of 77.25 (range, 67-88). After surgery, AOFAS score showed a marked improvement in all the cases, with an average of 95.6 (range, 87-100). Improvement in AOFAS score results was statistically significant, both for sign test for matched pairs (P=0.008) and for Wilcoxon signed-rank test (P=0.012). All of the patients were satisfied with the results of the procedure, and would undergo it again.

Conclusions

Autologous quadriceps tendon graft (in bone-tendon configuration) has proved as a simple technique that offers good results to patients with tissue defects in the Achilles tendon.

Optimal Outcomes for Acute Avulsion Fracture of the Achilles Tendon Treated With the Insertional Reattachment Technique: A Case Series of 31 Cases With Over 2 Years of Follow-up

BACKGROUND

Avulsion fracture of the Achilles tendon is a less common but debilitating disorder. There is a paucity of literature on this problem.

PURPOSE

To present a retrospective case series assessing the clinical outcomes of avulsion fracture of the Achilles tendon after a reattachment procedure and to identify potential factors predicting postoperative outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A consecutive case series of 35 patients with acute insertional rupture of the Achilles tendon who received a reattachment procedure between 2011 and 2017 were reviewed. All patients were measured and classified by magnetic resonance imaging (MRI) and surgical findings. Patient-reported outcomes were evaluated using the visual analog scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Foot Function Index (FFI), Tegner score, and Ankle Activity Score (AAS). The range of motion and single-legged heel raise test were also conducted for both ankles.

RESULTS

Thirty-one out of 35 (88.57%) patients were followed up for an average of 43.65 months. The VAS pain score and AOFAS Ankle-Hindfoot score improved from 4.87 ± 1.61 preoperatively to 2.07 ± 1.57 postoperatively and from 58.32 ± 18.66 preoperatively to 87.32 ± 7.53 postoperatively, respectively (both P < .001). The mean FFI, AAS, and Tegner scores after the operation were 11.84 ± 1.62, 5.71 ± 2.18, and 4.61 ± 1.31, respectively. Compared with the intact ankle, the mean deficit in dorsiflexion in the involved ankle was 9.54°± 6.25° (range, 0.59°-23.70°; P < .001) and the mean deficit in plantarflexion in the involved ankle was 6.31°± 4.02° (range, 0.24°-14.92°; P < .001). Thirty patients could perform the single-legged heel raise on the operative leg. A larger body mass index was associated with worse postoperative AOFAS and FFI outcomes. Longer follow-up predicted statistically significantly better FFI scores. Better postoperative dorsiflexion was associated with better postoperative FFI, AAS, and Tegner scores, and a statistically significant interaction was found between the VAS score and plantarflexion deficit. Age, preoperative insertional tenderness, Haglund deformity, and MRI classification showed little association with postoperative outcomes.

CONCLUSION

This study demonstrated that the reattachment procedure for acute avulsion fracture of the Achilles tendon can achieve firm fixation and promising outcomes.

Open Reconstructive Strategies for Chronic Achilles Tendon Ruptures

Chronic Achilles tendon ruptures typically are treated with surgical intervention except in low-demand patients or patients who are unable to tolerate surgery. Although several treatment strategies are described, most literature is case reports and case series. There is no widely accepted algorithm or gold standard for surgical treatment of chronic Achilles tendon ruptures. Treatment strategy depends on the size of the tendon gap after excision of nonviable tissue and scar tissue. Smaller gaps can be treated with direct end-to-end repair. Medium-sized gaps can be treated with tendon-lengthening procedures. Tendon transfers, autograft, allograft, xenograft, and synthetic grafting are described for the reconstruction of large defects.

Validity and Reliability of Mini-Invasive Surgery Assisted by Ultrasound in Achilles Tendon Rupture

Introduction:

The surgical treatment for Achilles tendon rupture has become very popular in the last years, because of the good outcomes and the low re-rupture rate.

Aim:

The aim of this study is to compare the results between open surgery and percutaneous ultrasound-assisted surgery.

Methods:

All patients who underwent an Achilles tendon surgical repair in the last 3 years were included, resulting in a total of 56 patients (40 M and 16 F) with an average age of 53 years. Of these patients, 36 were treated with an open suture, while 20 with a mini invasive ultrasound assisted suture. At a minimum follow-up of one year, patients were evaluated echografically, using both the Achilles Tendon Rupture Total score (ATRS) and the McComis score, and performing the ultrasounds bilaterally to assess both the structure and the diameter of tendons.

Results:

Both groups of patients showed an average ATRS score >80. The McComis score was 54.18 vs. 56.25 (p>0.05). Plantar flexion and dorsal flexion work were not similar (p>0.05). On average, the calf circumference of the operated side was decreased compared to the healthy side between the groups (p>0.05). The thickness of the operated tendons evaluated with ultrasound measurement compared to the average tendon, (p <0.05).

Conclusion:

The ultrasound-assisted tenorrhaphy is a reliable treatment with good clinical and functional outcomes; anyway, the percutaneous technique and the open surgery show similar results.

Chronic Achilles Ruptures: Reconstructive Options

Achilles tendon ruptures, if neglected or identified late, lead to impairments in function and gait. Surgical reconstruction is typically required to restore the resting length and tension to the gastrocnemius-soleus complex. A variety of reconstructive options have been described, depending on several factors, including chronicity, residual gap size, remaining tissue quality and vascularity, location of tendon rupture or deficiency, and patient-specific factors. Despite the many surgical options described from local soft-tissue rearrangements and tendon transfers, to the use of allograft tissue and synthetic material augmentation, there is understandably a paucity of evidence-based guidelines available to direct surgeons in the optimal procedure for each patient-specific situation. Reconstructive options for the patient with a chronic Achilles rupture are detailed and reviewed here, to serve as a framework for the treating surgeon in these complex cases.

Surgical management of chronic Achilles tendon ruptures using less invasive techniques

BACKGROUND

Surgical management of chronic Tendo Achillis (TA) ruptures usually requires tendon grafting procedures. Several techniques have been described. We examined the outcome of three different less invasive (incisions length less than 3 cm) tendon transfer techniques in the management of patients with a chronic rupture of the TA.

METHODS

Of 62 patients (39 males and 23 females; mean age 44.8 years; range 29.3-62 years) with chronic TA ruptures managed operatively, 21 patients had a ≥6cm gap and underwent free ipsilateral semitendinosus (ST) graft (21 patients), whereas patients with smaller gaps had either ipsilateral peroneus brevis (PB) (20 patients) or ipsilateral flexor hallucis longus (FHL) transfer (21 patients). Outcome measures included maximum calf circumference, isometric plantar flexion strength, and the Achilles tendon total rupture score (ATRS), preoperatively and at the last follow up. We also recorded the time to return to activities of daily living (ADL) and sports, and the number of single-leg heel lifts on the affected leg at the last follow up, at an average of 35.4 months.

RESULTS

Patient characteristics between groups were similar. All outcome measures significantly improved after surgery (p<0.001), without differences between the three groups. Return to ADL was possible at an average of 4.5 months. Patients undergoing PB transfer had a slower return to sports compared to the other groups, at 6.9±0.5months versus 6.1±0.8 for the FHL and 5.8±0.6 for the ST groups (t-test p=0.005 and p<0.001, respectively). However, 13/14 patients (90%) in the PB group returned to high impact sports, compared to 9/12 (75%) in the FHL and 6/11 (55%) in the ST groups (Fisher's test, p=0.31 and p=0.056, respectively).

CONCLUSION

All three techniques produced significant functional improvement, and return to sports was possible in most patients. This study does not demonstrate a clear advantage of one technique over the others.

Outcome after operative treatment for chronic versus acute Achilles tendon rupture - A comparative analysis

BACKGROUND

This study compared outcomes after treatment of acute Achilles tendon (AT) rupture via percutaneous suturing, with those after chronic AT rupture treated via open reconstruction.

METHODS

This retrospective study included 30 patients who underwent either percutaneous suturing for acute AT rupture (group AR, n=16) or open reconstruction for chronic AT rupture (group CR, n=14). Function was evaluated by calf muscle circumference, and endurance through isokinetic measurement and single-leg heel-rise test. Score evaluation included AT Total Rupture Score, Victorian Institute of Sports Assessment-Achilles questionnaire, and visual analogue scale pain score. Postoperative tendon thickness was measured using ultrasonography and MRI.

RESULTS

Follow-up was conducted 4.97±1.79 years postoperatively. The groups were similar in age and body mass index. There was no significant difference between groups in calf circumference, isokinetic measurement, heel-rise test, and score evaluation. There was significantly less mediolateral tendon thickening in group AR compared with group CR on ultrasonography (p=0.01) and MRI (p=0.001).

CONCLUSIONS

Open reconstruction for chronic AT rupture may result in comparable clinical and functional outcomes, but a thicker tendon compared with percutaneous suturing after acute AT rupture.

Chronic Achilles Tendon Rupture

Background:

The Achilles tendon, the largest and strongest tendon in the human body, is nevertheless one of the tendons which most commonly undergoes a complete subcutaneous tear. Achilles tendon ruptures are especially common in middle aged men who occasionally participate in sport. Even though Achilles tendon ruptures are frequent, up to 25% of acute injuries are misdiagnosed, and present as chronic injuries.

Methods:

This is a review article about diagnosis and management of chronic Achilles tendon ruptures. Minimally invasive Achilles tendon reconstruction is discussed.

Results:

The optimal surgical procedure is still debated, however, less invasive peroneus brevis reconstruction technique and free hamstring autograft provide good functional results.

Conclusion:

The management of chronic ruptures is more demanding than acute tears, because of the retraction of the tendon ends, and the gap makes primary repair impossible. Wound complications and infections are frequent after open procedures. Minimally invasive treatments provide good functional results and lower complications rate.

Endoscopy-Assisted Achilles Tendon Reconstruction With a Central Turndown Flap and Semitendinosus Augmentation

BACKGROUND

The objective of this study was to report the results of a new minimally invasive Achilles reconstruction technique and to assess the perioperative morbidity, medium- to long-term outcomes, and functional results.

METHODS

Our series was comprised 14 patients (11 men and 3 women), with a mean age of 45.6 years at surgery. Each patient had a chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (range, 2-10). The mean total follow-up was 30.1 months (range, 12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach assisted by endoscopy. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion.

RESULTS

The length of the defect ranged from 3 to 8 cm (mean, 5.1), while the length of the turndown flap ranged from 8 to 13 cm (mean, 10.1). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at last follow-up. The mean ATRS score improved from 49.4 preoperatively to 91.4 points at last follow-up. None of the patients developed a wound complication. No patient had a rerupture or sural nerve damage.

CONCLUSION

All patients in our study had a favorable outcome with no complications. We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps

BACKGROUND

Several surgical procedures for chronically ruptured Achilles tendons have been reported. Resection of the interposed scar tissue located between the tendon stumps and reconstruction using normal autologous tissue have been well described. We developed a direct repair procedure that uses scar tissue, which obviates the need to use normal autologous tissue.

METHODS

Thirty consecutive patients with Achilles tendon ruptures with a delay in diagnosis of >4 weeks underwent removal of a section of scar and healing tissue with direct primary suture of the ends of the tendon without the use of allograft or autograft. Patients were followed for a mean time of 33 months. Preoperative and postoperative clinical outcomes were measured with the Achilles Tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. In addition, the patients underwent preoperative and postoperative functional measurements and magnetic resonance imaging. Lastly, we evaluated the histology of the interposed healing tissue.

RESULTS

The mean AOFAS scores were 82.8 points preoperatively and 98.1 points postoperatively. The mean postoperative ATRS was 92.0 points. At the time of the latest follow-up, none of the patients had experienced tendon reruptures or difficulties in walking or climbing stairs, and all except 2 patients could perform a single-limb heel rise. All athletes had returned to their pre-injury level of sports participation. Preoperative T2-weighted magnetic resonance imaging showed that 22 Achilles tendons were thickened with diffuse intratendinous high-signal alterations, and 8 Achilles tendons were thinned. Postoperative T2-weighted magnetic resonance imaging findings included fusiform-shaped tendon thickening and homogeneous low-signal alterations of the tendons in all patients. Histologically, the interposed scar tissue consisted of dense collagen fibers.

CONCLUSIONS

Shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for treatment-delayed or neglected Achilles tendon rupture.

LEVEL OF EVIDENCE

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

Chronic Achilles tendon rupture reconstructed using hamstring tendon autograft

BACKGROUND

Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and augmentation methods are challenging when the defect exceeds 5-6 cm, especially if the distal stump is grossly tendinopathic.

METHODS

We describe our method of Achilles tendon reconstruction with ipsilateral semitendinosis autograft and interference screw fixation in a patient with chronic rupture, a 9 cm defect and gross distal tendinopathy.

RESULTS

Patient reported outcome measures consistently demonstrated improved health status at 12 months post surgery: MOXFQ-Index 38-25, EQ5D-5L 18-9, EQ VAS 70-90 and VISA-A 1-64. The patient was back to full daily function, could single leg heel raise and was gradually returning to sport. No complications or adverse events were recorded.

CONCLUSION

Reconstruction of chronic tears of the Achilles tendon with large defects and gross tendinopathy using an ipsilateral semitendinosis autograft and interference screw fixation can achieve satisfactory improvements in patient reported outcomes up to 1 year post-surgery.

Successful treatment of a fracture of a huge Achilles tendon ossification with autologous hamstring tendon graft and gastrocnemius fascia flap: a case report

Background

Fracture of an ossified Achilles tendon is a rare entity, and no standard treatment has been established. This is the first report to describe the use of a hamstring tendon graft and gastrocnemius fascia flap for Achilles tendon reconstruction.

Case presentation

We present the case of a 50-year-old woman with fracture of an ossified Achilles tendon. She presented to our clinic with acute right hindfoot pain, which started suddenly while going up the stairs. Plain radiography and magnetic resonance imaging revealed a massive ossification on the right Achilles tendon extending over 14 cm in length; the ossification was fractured at 5 cm proximal to the calcaneus insertion. Surgical treatment included removal of the ossified tendon and reconstruction with an autologous hamstring tendon graft and gastrocnemius fascia flap. One year after surgery, she was able to walk with little pain or discomfort and to stand on her right tiptoe.

Conclusion

Our novel surgical procedure may be useful in the treatment of fractured ossified Achilles tendons and large Achilles tendon defects.

Reconstruction of defects involving the Achilles tendon and local soft tissues

A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7).

At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (sd 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (sd 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction.

These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction.

Cite this article: Bone Joint J 2015;97-B:215–20.