Outcomes After Primary Repair of Insertional Ruptures of the Achilles Tendon

Achilles Tendon Rupture

There are many high-level studies comparing nonoperative treatment, open repair, and minimally invasive repair for Achilles tendon ruptures. This article summarizes the most up-to-date literature comparing these treatment options. The authors' preferred protocol for nonoperative treatment is discussed. Preferred techniques for open repair and chronic Achilles repair are discussed with reference to the literature.

A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients

INTRODUCTION

Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients.

MATERIALS AND METHODS

This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65 years (group 1, 13 patients) and < 65 years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position.

RESULTS

The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively.

CONCLUSION

We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.

Return to sport after surgical repair of the Achilles tendon

Achilles tendon rupture is among the most common sports injuries. In patients with high functional demands, surgical repair is preferred to facilitate early return to sporting function. This article reviews the literature and provides evidence-based guidance for return to sport after operative management of Achilles tendon rupture. A search was performed using PubMed, Embase and Cochrane Library for all studies reporting on return to sport after operative management of Achilles tendon rupture. The review included 24 studies reporting on 947 patients, and found that 65-100% of patients were able to return to sport between 3 and 13.4 months post-injury, with incidence of rupture recurrence 0-5.74%. These findings will help patients and healthcare professionals plan a recovery timeline, discuss athletic functionality post-recovery, and understand complications of repair and risk of tendon re-rupture.

Bilateral distal Achilles tendon sleeve avulsion: a case report

BACKGROUND

While Achilles tendon rupture is a common injury sustained especially in sporting events, distal Achilles tendon rupture is less common. Even rarer is a bilateral traumatic distal Achilles tendon sleeve rupture, with outcomes of such injury unknown. The following case report describes this rare injury, not reported to date elsewhere.

CASE

A 57-year-old Finnish man with no predisposing medical history had a traumatic bilateral distal Achilles tendon sleeve avulsion injury. Clinical and radiological evaluation confirmed the diagnosis. Treatment included suture anchors in a modified suture bridge style with customized rehabilitation protocol postoperatively. Symptoms continued to be relieved at 1 year postoperatively.

CONCLUSION

A modified suture bridge style and meticulous rehabilitation protocol including motivated patient contributed to very satisfying results in this very rare bilateral injury.

The Relationship Between Patient Demographics, Tear Locations, and Operative Techniques on the Surgical Treatment of Acute Achilles Tendon Ruptures

Introduction

Achilles tendon ruptures (ATRs) have classically been thought to affect the middle-aged “weekend warrior” participating in basketball, volleyball, soccer, or any ground sport; however, with a more active elderly population, these tears are becoming more common in older patients. We sought to examine the role of demographics, tear location, and operative technique for acute Achilles tendon ruptures treated surgically.

Methods

A retrospective query was performed to identify patients who presented with Achilles tendon ruptures. Inclusion data were primary end-to-end repairs, augmented repairs with flexor hallucis longus (FHL) transfers, augmented repairs with graft, augmented repairs with both FHL transfer and graft use, isolated FHL transfers, and revision Achilles tendon procedures. Demographics and tear locations were collected and analyzed.

Results

Midsubstance tears were the most common tear location occurring in 237 of 286 (82.9%) patients. Distal insertional tears of the Achilles tendon were treated in 35 (12.2%) patients, while 14 (4.9%) patients had a more proximal tear located at the myotendinous junction. Older patients (average age: 53.3±12.5) had significantly more distal insertional tears (p<0.001), while younger patients (average age: 35.1±7.4) presented with significantly more tears at the myotendinous junction (p<0.001). The average BMI was significantly higher (average BMI: 32.2±6.6; p<0.001) in patients with distal insertional tears compared to midsubstance and proximal tears (28.5±4.6 and 28.5±5.3, respectively). There was a higher percentage of diabetic patients who underwent operative treatment for distal insertional tears (20%) compared to midsubstance tears (7.2%).

Conclusion

The findings of our study suggest that a subset of patients, particularly those with advanced age and higher BMI, is more likely to present with a distal Achilles tendon rupture. Additionally, patients in our series who had distal tears more commonly required an augmented repair technique. Our results highlight the need for future research to further define the relationship between increasing age and higher BMI patients sustaining distal tears more often than midsubstance tears.

[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.

Insertional versus non-insertional tendoachilles tears: a comparative analysis of various predisposing factors and outcome following a repair

BACKGROUND

Association of tendon degeneration, pre-existing posterior heel pain, Haglund's bump, retrocalcaneal spur, and mode of injury varies for the insertional and non-insertional type of tendoachilles tears (TA).

PURPOSE

The study compares the various predisposing factors that determine the distinct type of TA tear and the outcome following a repair.

METHODS

This is a retrospective study of the patients who underwent tendoachilles repair during January 2012-June 2018. Patients above 18 years with a minimum follow-up of two years were included. Patients with calcaneal tuberosity avulsions, prior surgeries, and open injuries were excluded. Patients were divided into groups 1 (insertional tears (IT)) and 2 (non-insertional tears (NIT)), and further subdivided based on the tendon degeneration (as D-degenerative and N-normal sub types) from ultrasound findings. AOFAS score and predisposing factors like degeneration, posterior heel pain, Haglund's bump, spur, and mechanism of injury were compared between the groups.

RESULTS

The study included N = 146 with a mean age of 51.6 years and mean follow-up of 38.6 (range 24 to 96) months. IT associated with degeneration (IT-D) had a trivial fall as the predominant mechanism (P < 0.001). All patients had significant postoperative improvement of scores with no significant difference between the groups (P = 0.59) and subgroups (P = 0.27).75.34% had degenerative tendon, of which 64.5% were in the IT group and the rest in the NIT group (P = 0.02). 51.4% patients had a Haglund bump in the IT group and n.s. (P = 0.9). Forty-seven percent of patients had pre-existing posterior heel pain, 68% in IT and 32% in NIT (P = 0.04). Subgroup analysis revealed 65% of patients were in the IT-D subgroup (P < 0.001).

CONCLUSION

Predisposing factors like posterior heel pain, tendon degeneration, and trivial trauma have a strong propensity for insertional TA tear. In contrast, the prominence of Haglund's bump does not predispose to a distinct type of TA tears. The outcome following a surgical repair-yields good results with no difference between the two groups.

Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures in Professional Soccer Players

BACKGROUND

Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR.

METHODS

Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated.

RESULTS

All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength.

CONCLUSION

The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort.

LEVEL OF EVIDENCE

Level II, prospective cohort case series study.

Morphology of Acute Achilles Tendon Rupture by Intraoperative Evaluation

The purpose of this study was to clarify the morphology of acute Achilles tendon rupture (ATR) according to intraoperative evaluation. The morphology of 220 cases was evaluated retrospectively from intraoperative findings from June 2014 to December 2015. We noted 3 characteristics of rupture. First, we divided the ruptures into complete or partial type. Second, according to the level of rupture, we classified them into muscle-tendon junctional type, mid-substantial type, or calcaneal insertional avulsion type. Lastly, on the basis of the pattern of rupture, we divided them into transverse pattern, double-layer pattern, or Z-shaped pattern. All ruptured tendons were repaired with surgical procedures on the basis of the classification of rupture type or pattern. Of the total of 220 cases, 217 were complete ruptures (98.7%) and 3 partial ruptures (1.3%). Regarding the level of rupture, 5 cases were of the muscle-tendon junctional type (2.3%), 209 cases of the mid-substantial type (95%), and 6 cases of the calcaneal insertional avulsion type (2.7%). In terms of the pattern of rupture, there were 198 cases of the transverse pattern (90%), 10 cases of the double-layer pattern (4.5%), and 12 cases of the Z-shaped pattern (5.5%). There was significant gender difference only in the mid-substantial type. Although the morphology of a typical acute ATR was complete, of mid-substance type, and with transverse pattern, other types of ATR were recognized from the intraoperative investigation.

Influence of Achilles tendon rupture site on surgical repair outcomes

PURPOSE

This study aims to measure the distance between the common site of Achilles tendon rupture and calcaneal insertion through ultrasound and to compare the outcomes between proximal and distal rupture groups.

METHODS

We investigated the electronic medical records of 117 patients and preoperative ultrasound describing the rupture site. Among 88 patients, we compared the patient-reported outcome and re-rupture rate of proximal and distal rupture groups.

RESULTS

The mean rupture site of the 117 included subjects was 4.5 ± 1.3 cm. The rupture site had a weak negative correlation with body mass index (ρ = -0.230, P = 0.013). Furthermore, 77% of the patients with distal rupture reported good outcome (Achilles Tendon Rupture Score > 80) compared to 56% of the patients with proximal rupture (P = 0.041).

CONCLUSION

Patients with proximal rupture had less satisfactory postoperative outcomes than those with distal rupture.

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.

Effect of Achilles Tendon Rupture on Player Performance and Longevity in National Basketball Association Players

Background:

National Basketball Association (NBA) players who return to sport (RTS) after Achilles tendon rupture have been reported to have poor outcomes.

Purpose:

To evaluate the effect of Achilles tendon ruptures on player performance and career longevity in NBA athletes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

NBA players who sustained Achilles tendon ruptures between 1970 and 2019 were identified using publicly available resources and were matched 1:1 to a healthy control group by age, position, height, and body mass index. Demographic characteristics, player utilization (games and minutes), and performance efficiency rating (PER) were documented for all athletes. The season of Achilles tendon rupture was set as the index year, and statistical analysis compared postindex versus preindex data both acutely and in the long term. Percentages relative to preoperative values were calculated to compare the injured and control groups in a standardized fashion.

Results:

Of 47 players, 34 (72.3%) with Achilles tendon ruptures returned to play at the NBA level after surgical intervention. A total of 7 players were excluded from the study. No differences were found in demographic characteristics or PER (2 years before injury) between the remaining 27 players and matched controls. The injured players had significantly shorter careers compared with control players (3.1 ± 2.3 vs 5.8 ± 3.5 seasons, respectively; P < .05). Injured players demonstrated significant declines in games per season (GPS), minutes per game (MPG), and PER at 1 year and 3 years after RTS compared with preindex baseline (P < .05). Injured players, compared with control players, had reduced relative percentages of games started (GS) (50% vs 125%, respectively), MPG (83% vs 103%), and PER (80% vs 96%) at 1 year after return (P < .05), but reductions at extended 3-year follow-up were seen only in GPS (71% vs 91%) and GS (39% vs 99%) (P < .05).

Conclusion:

Our study found that 72.3% of NBA players returned to play after Achilles tendon repair, but they had shorter careers compared with uninjured controls. Players returning from Achilles tendon repairs had decreased game utilization and performance at all time points relative to their individual preindex baseline. However, for the injured players when compared with controls, game utilization but not performance was found to be decreased at 3-year follow-up.

Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears

INTRODUCTION

Very distal tears of the Achilles tendon are uncommon, and poor quality tendinous tissue of the calcaneal stump can compromise healing. Little has been published about the characteristics and surgical management of such injuries. We present a surgical technique, developed by the senior author, to restore continuity of the gastrosoleus-Achilles tendon-calcaneus complex using a free ipsilateral semitendinosus graft, and clinical outcomes of a case series of 28 consecutive patients. Our hypothesis was that this is a safe technique, and patients can return to pre-injury occupation and athletic activities.

PATIENTS AND METHODS

A total of 28 patients (mean age 46 years) underwent minimally invasive reconstruction using a free ipsilateral semitendinosus graft for acute insertional rupture of tendo Achillis. The procedure required two small incisions along the course of the Achilles tendon, and one posteromedial incision at level of the ipsilateral knee to harvest the semitendinosus tendon. Patients were assessed at minimum 2 years (range, 2-2.5 years) following the index procedure.

RESULTS

The median Achilles tendon Rupture Score (ATRS) at the latest follow-up was 88. Two patients developed a superficial wound infection. All patients returned to their preinjury occupation, whilst 22 out of 28 patients (79%), returned to their preinjury level of physical activity at a mean of 6.7 months after surgery, reporting good or excellent overall satisfaction in 88.5% of cases.

CONCLUSION

This minimally invasive technique was safe, and allowed most of patients to return to preinjury daily and sport activities within 9 months from surgery.

Repair of Achilles sleeve avulsion: a new transosseous suture technique

BACKGROUND

Achilles sleeve avulsion usually occurs from pre-existing insertional Achilles tendinopathy, leaving a calcific spur at the insertional site. The purpose of this study was to introduce a new technique using the spur base on the insertional site to drill the suture tunnel to repair Achilles sleeve avulsion.

METHODS

In total, 11 patients diagnosed with Achilles sleeve avulsion underwent this new surgical technique and were followed for a mean time of 40 months. Clinical outcomes were measured using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Tegner score, and time taken to return to activities. Preoperative and postoperative MRI, the ability to perform heel rise, and complications were also evaluated.

RESULTS

All cases (11/11) had insertional Achilles tendinopathy with calcific spur formation on the tendon's insertion. At final follow-up, the average VAS score improved from 5.3 to 0.1, AOFAS score improved from 44.8 to 97.9, VISA-A score improved from 23.6 to 96.6, and Tegner score improved from 0.9 to 4.9. Tendinopathy symptoms were eliminated. Patients returned to daily activities, work, and sports 3.5 months, 2.8 months, and 12.3months after operation, respectively. Patients took an average of 18.1 weeks after operation to perform the single heel rise test. No severe complications such as infection and rerupture were observed.

CONCLUSION

Our new transosseous suture technique is a promising alternative option in treating Achilles sleeve avulsion. More cases and longer follow up are needed in order to find the best reconstructive option for this pathology.

LEVELS OF EVIDENCE

Level IV.

Repair of Combined Insertional and Midsubstance Achilles Tendon Ruptures

Complex combined tears of the insertion and midsubstance of the Achilles tendon are rare injuries that are challenging to diagnose and treat. The author describes a novel technique for combined insertional and midsubstance Achilles repair that decreases proximal soft tissue dissection, restores musculotendinous length, and directly fixes tendon to bone in a strong, knotless fashion to allow for early mobilization and functional recovery. [Orthopedics. 2020; 43(1):e57-e64.].

Reduced Myogenic and Increased Adipogenic Differentiation Capacity of Rotator Cuff Muscle Stem Cells

BACKGROUND

Fat accumulation commonly occurs in chronically torn rotator cuff muscles, and increased fat within the rotator cuff is correlated with poor clinical outcomes. The extent of lipid deposition is particularly pronounced in injured rotator cuff muscles compared with other commonly injured muscles such as the gastrocnemius. Satellite cells, which are a tissue-resident muscle stem-cell population, can differentiate into fat cells. We hypothesized that satellite cells from the rotator cuff have greater intrinsic adipogenic differentiation potential than do gastrocnemius satellite cells, and this difference is due to variations in epigenetic imprinting between the cells.

METHODS

Satellite cells from gastrocnemius and rotator cuff muscles of mice were cultured in adipogenic media, and the capacity to differentiate into mature muscle cells and adipogenic cells was assessed (n ≥ 9 plates per muscle group). We also performed DNA methylation analysis of gastrocnemius and rotator cuff satellite cells to determine whether epigenetic differences were present between the 2 groups (n = 5 mice per group).

RESULTS

Compared with the gastrocnemius, satellite cells from the rotator cuff had a 23% reduction in myogenic differentiation and an 87% decrease in the expression of the differentiated muscle cell marker MRF4 (myogenic regulatory factor 4). With respect to adipogenesis, rotator cuff satellite cells had a 4.3-fold increase in adipogenesis, a 12-fold increase in the adipogenic transcription factor PPARγ (peroxisome proliferator-activated receptor gamma), and a 65-fold increase in the adipogenic marker FABP4 (fatty-acid binding protein 4). Epigenetic analysis identified 355 differentially methylated regions of DNA between rotator cuff and gastrocnemius satellite cells, and pathway enrichment analysis suggested that these regions were involved with lipid metabolism and adipogenesis.

CONCLUSIONS

Satellite cells from rotator cuff muscles have reduced myogenic and increased adipogenic differentiation potential compared with gastrocnemius muscles. There appears to be a cellular and genetic basis behind the generally poor rates of rotator cuff muscle healing.

CLINICAL RELEVANCE

The reduced myogenic and increased adipogenic capacity of rotator cuff satellite cells is consistent with the increased fat content and poor muscle healing rates often observed for chronically torn rotator cuff muscles. For patients undergoing rotator cuff repair, transplantation of autologous satellite cells from other muscles less prone to fatty infiltration may improve clinical outcomes.