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

The Effectiveness of the Modified Side-Locking Loop Suture Technique with Early Accelerated Rehabilitation for Acute Achilles Tendon Rupture in Athletes

Background/Objectives: An early accelerated rehabilitation is generally recommended after surgery for acute Achilles tendon ruptures (ATRs). The modified side-locking loop suture (MSLLS) is a surgical technique that provides high tensile strength to the repaired Achilles tendon and allows for a safe, early accelerated rehabilitation protocol without requiring postoperative immobilization. However, there are no reports investigating the clinical outcomes of the MSLLS technique with early accelerated rehabilitation for ATRs. To clarify the effectiveness of the MSLLS technique with an early accelerated rehabilitation protocol for ATR in athletes. Methods: We retrospectively analyzed 27 athletes (Tegner activity score ≥ 6) who underwent surgical treatment using the MSLLS technique for ATR between April 2017 and August 2022. All patients underwent an early accelerated rehabilitation protocol without immobilization. Outcome measures included the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score taken preoperatively and one year postoperatively, the time required to perform 20 continuous double-leg heel raises (DHR) and single-leg heel raises (SHR), the time to return to the original sport, and the presence of any complications. Results: The mean AOFAS score significantly improved from 37.2 ± 9.7 preoperatively to 96.3 ± 5.3 one year postoperatively. The mean time to be able to perform 20 continuous DHR and SHR was 7.7 ± 1.2 weeks and 11.3 ± 1.6 weeks, respectively. All patients were able to return to their original sport at their pre-injury level in an average of 22.7 ± 3.7 weeks without complication. Conclusions: The MSLLS technique in conjunction with an early accelerated rehabilitation protocol for ATR in athletes produced satisfactory results, with all patients able to return to their original sport at their preinjury level without complication.

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.

Avulsion fracture of the calcaneal tuberosity treated with novel surgical technique using the combination of the side-locking loop suture technique and ring pins: a case report

A 78-year-old woman complained of right heel pain when tripping during walking. Radiographs revealed an avulsion fracture of the calcaneal tuberosity. Because the bone fragment was displaced, a novel osteosynthesis using the side-locking loop suture (SLLS) and ring pins was performed. At 3 months after the surgery, non-contrast computed tomography revealed complete bone union. At 2 years postoperatively, she had no symptoms and dysfunctions. Here, we describe a case of avulsion fracture of the calcaneal tuberosity in a 79-year-old female who treated with a novel surgical technique using combination the SLLS technique and ring pins. This surgical technique may be a useful option in the treatment for avulsion fractures of the calcaneal tuberosity.

Endoscopic-assisted locking block modified Krackow technique combined with a V-Y flap for chronic Achilles tendon rupture

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of the endoscopic-assisted locking block modified Krackow technique with a V-Y flap. The hypothesis was that the minimally invasive technique can reduce wound complications and facilitate early recovery.

METHODS

In total, 29 men with chronic Achilles tendon rupture who underwent either minimally invasive technique (n = 13) or open repair (n = 16) at our department between 2013 and 2019 were retrospectively analyzed. The rate of complications, time to return to moderate-intensity exercise, American Orthopedic Foot and Ankle Society ankle hindfoot score, Achilles tendon Total Rupture Score, heel-rise repetitions in 1 min, heel-rise height, and bilateral calf circumference at 6 months, 1 year, and 2 years postoperatively were recorded.

RESULTS

All incisions healed primarily in the minimally invasive technique group; however, three patients in the open repair group experienced wound complications. The time to return to moderate-intensity exercise, American Orthopedic Foot and Ankle Society score, Achilles tendon Total Rupture Score, heel-rise repetition ratio, and heel-rise height ratio at 6 months postoperatively in the minimally invasive technique group were significantly better than those in the open repair group. However, it was not significantly different between both groups at 2 years postoperatively.

CONCLUSION

Endoscopy allowed scar tissue and adhesions to be removed, allowing the tendon ends to be mobilized out of the small proximal and distal incisions. Minimally invasive technique may result in a lower wound complication incidence and provide better early functional recovery and return to moderate-intensity exercise time than the conventional open procedure in treating chronic Achilles tendon ruptures.

CLINICAL TRIAL REGISTRATION

Wuxi Ninth People's Hospital Medical Ethical Committee, LW2021026.

LEVEL OF EVIDENCE

III.

Return to the original sport at only 3 months after an Achilles tendon rupture by a combination of intra-tissue injection of freeze-dried platelet-derived factor concentrate and excessively early rehabilitation after operative treatment in a male basketball player: A case report

Background

Achilles tendon rupture is one of the most common serious injuries in athletes. Various studies to accelerate the healing process of the Achilles tendon have been performed as it takes a longer time to repair the tissue compared to other tendons. Here, we report a case of an acute Achilles tendon rupture in a male basketball player treated by a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate, which included a platelet-derived growth factor with an early rehabilitation protocol after the operative treatment to facilitate the biological healing of the injured tendon tissue. To the best of our knowledge, this case is the first instance that enabled the athlete to return to original sport activity at only 3-months after the injury.

Case report

A 23-year-old male basketball player who belonged to a university basketball team sustained an Achilles tendon rupture during running in a training match. The remaining time period until the final tournament of the university league as a senior player was only 3 months. The patient received a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate and early rehabilitation protocol after operative treatment. Surgery was performed 4 days after the injury and the early rehabilitation protocols were applied postoperatively. A freeze-dried platelet-derived factor concentrate was injected into the ruptured site of the Achilles tendon under ultrasound guide at 4 weeks postoperatively. The patient could return to play at the pre-injury level without any symptoms and disfunctions at 3 months after surgery. At two years postoperatively, the patient could play basketball without symptoms or rerupture.

Conclusions

We reported a case of an Achilles tendon rupture which was treated by a combination of intra-tissue injection of freeze-dried platelet-derived factor concentrate and an early rehabilitation protocol after the operative treatment. The patient could return to play basketball at the pre-injury activity level at only 3-months after the injury, suggesting that the role of applying excessively early rehabilitation of mechanical loading could facilitate tendon tissue healing when combined with an intra-tissue injection of freeze-dried platelet-derived factor concentrate.

•

FD-PFC has rich growth factors such as PDGF-BB, which is a part of the PDGF growth family.

•

An achilles tendon rupture was treated by a combination of injection of FD-PFC and excessively postoperative rehabilitation.

•

The patient could return to play basketball at the pre-injury activity level at only 3-months after the injury.

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.

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.

Atraumatic Spontaneous Achilles Tendon Rupture in Patients Receiving Oral Corticosteroids Treated With the Modified Side-Locking Loop Suture Technique

Atraumatic spontaneous Achilles tendon ruptures sometimes occur in patients receiving oral corticosteroids. In general, these cases are treated surgically; however, delayed postoperative management can lead to impaired activities of daily living. The modified side-locking loop suture (SLLS) technique is a useful suture method for safe and early active mobilization. Three cases of spontaneous Achilles tendon ruptures were treated with the modified SLLS technique with good clinical results. The modified SLLS technique is a useful method with a short rehabilitation period for treating atraumatic spontaneous Achilles tendon rupture in patients undergoing corticosteroid therapy.