Postoperative Complications Following Repair of Acute Achilles Tendon Rupture

Differences in Player Performance and Longevity After Achilles Tendon Rupture Between Professional Basketball Players in the NBA and WNBA

Background

Prior studies in the National Basketball Association (NBA) and Women's National Basketball Association (WNBA) reported worse player performance after Achilles tendon rupture (ATR).

Purpose/Hypothesis

The purpose of this study was to compare time to return to play (RTP) and performance after ATR between NBA and WNBA athletes. It was hypothesized that there would be no relative difference between the NBA and WNBA players.

Study Design

Cohort study; Level of evidence, 3.

Methods

ATRs in the NBA between 1987 and 2017 and WNBA between 2006 and 2017 were identified through a rigorous online search of articles. Included athletes had no prior leg injuries and had played ≥3 seasons before and after ATR. Sex, age, position, body mass index, height, years of experience, time to RTP, and player efficiency rating (PER) were recorded. Relative performance was measured by matching injured athletes to uninjured controls in the same league in a 1:2 ratio. Relative differences were compared between leagues, with adjustment for baseline features. Multiple regression analysis was employed to identify variables correlating with RTP and PER.

Results

Included were 102 professional basketball players, of whom 34 sustained ATR (21 male, 13 female). Sex/league correlated with differences in RTP (P < .001). There was a significant difference between the WNBA and NBA in PER when comparing 1 year pre- and 1 year postinjury (1.49 ± 0.25 vs 3.87 ± 0.43, respectively; mean ± SD P < .001). Compared with intraleague controls, the relative difference in PER postinjury was 0.81 ± 0.11 (WNBA) and 3.9 ± 0.89 (NBA) (P < .001). Multiple regression analysis indicated that when controlling for years of experience, player position, and age, NBA players took 126 days longer than WNBA players to RTP (P < .001) and NBA players had 9.96 times increased odds of taking >200 days to RTP compared with WNBA players (P = .006).

Conclusion

Sex/league was a significant predictor of RTP after ATR. When compared with their respective controls, NBA players saw a greater decrease in postinjury performance than WNBA players. NBA players took longer to RTP than WNBA players. ATRs appear to more negatively affect NBA players than WNBA players.

Open vs. Percutaneous Achilles Tendon Repair: Experience of Single Orthopedic Institute with Long-Term Follow-Up

Background and Objectives: There are numerous techniques for the surgical treatment of Achilles tendon lesions described in the literature, and it is possible to distinguish repair techniques as either open surgery or percutaneous repair techniques. Both approaches have advantages and disadvantages. With this retrospective study, we aim to analyze the incidence of re-ruptures and other complications, return to sport and overall quality of life at a long-term follow-up in the treatment of acute ATRs, comparing the results of percutaneous repair with those of open repair. Materials and Methods: This is a retrospective study on a consecutive series of patients with complete tear of the AT who were managed through a surgical approach by the Operative Unit of Orthopaedics and Traumatology of Sant'Anna University Hospital (Ferrara, Emilia-Romagna, Italy) between April 2014 and December 2021. Patients were treated with a percutaneous or an open technique according to the surgeon's preference without randomization. Results: We considered 155 patients who met the established inclusion criteria. Of these, 103 (66.45%) patients underwent percutaneous treatment with the Tenolig® system, and 52 (33.55%) underwent open surgery, with an average ATRS in the first group of 92.5 compared to an average ATRS value of 82 in patients treated with the open technique. Conclusions: In our experience, following overlapping rehabilitation protocols in all patients included, we observed that the Tenolig® repair system led to a better ATRS at long-term follow-up, with comparable complication rates to open surgery.

Derivation and validation of a risk calculator for the prediction of incidence of complications following repair of Achilles Tendon Rupture

BACKGROUND

The Achilles tendon is the body's strongest and largest tendon. It is commonly injured, particularly among athletes, accounting for a significant portion of serious tendon injuries. Several factors play a precipitating role in increasing the risk of these injuries.

OBJECTIVE

Our objective is to derive and validate a risk calculator for the prediction of incidence of any complication following Achilles tendon repair.

METHODS

We used de-identified data from the American College of Surgeons' National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2021. It comprises 7010 individuals who had undergone Achilles tendon rupture repair. Demographic and risk factors information was collected. To develop the calculator, the sample was divided into a derivation cohort (40%) and a validation cohort (60%). Multivariate logistic regression was used for statistical analysis, and a risk calculator for incidence of any complication was derived from the derivation cohort and validated on the remaining 60% of the sample. Patients with missing data were excluded, and the significance level was set at p < 0.05.

RESULTS

We analyzed the derivation cohort of 2245 individuals who underwent Achilles tendon repair surgery between 2005 and 2021, with a 5.5% overall complication. Multivariate logistic regression identified anesthesia type, ASA classification, certain co-morbidities (pre-operative dialysis and medication-requiring hypertension), and wound classification as significant predictors of complications. The developed risk calculator model had an area under the curve (AUC) of 0.685 in the derivation cohort and 0.655 in the validation cohort, surpassing the widely used and validated modified frailty index. A cut-off score threshold of 0.06 was established using Youden's index to dichotomize individuals into low and high risk for developing any postoperative complications.

CONCLUSION

Our risk calculator includes factors that most significantly affect the incidence of any complication following Achilles tendon repair.

Surgical Management of Achilles Tendon Ruptures in the United States 2006-2020, an ABOS Part II Oral Examination Case List Database Study

Background

In correlation with a growing body of evidence regarding nonoperative management for Achilles tendon rupture (ATR), studies from Europe and Canada have displayed a decreasing incidence in surgical management, which has not been noted in the United States. The primary objective of this study is to evaluate the US trend in ATR repair volume.

Methods

The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination Case List Database was used. All cases using Current Procedural Terminology codes for primary ATR repair were requested from the years 2006-2020. Total submitted Achilles repair volume, the number of candidates submitting an Achilles repair case, and the overall submitted case volume per examination year was analyzed. Poisson and linear regressions were used to determine statistically significant trends.

Results

The total number of Achilles repair cases submitted for the ABOS Part II Oral Examination significantly increased from 2006 to 2011 and then decreased until 2020. Taking Achilles repair cases as a proportion of total orthopaedic cases submitted, the same trend was seen. The number of candidates submitting an Achilles repair case increased from 2006 to 2009 and then decreased until 2020. Foot and Ankle fellowship-trained candidates submitted an increasing number of ATR repair cases per candidate during the time period studied.

Conclusion

This is the first study to demonstrate a decline in the volume of ATR repair in the United States. The decline in ATR repair volume seen in the ABOS Part II Case Lists does not match previously published US surgeon practice patterns but is not necessarily generalizable to beyond this period. Although the overall ATR repair volume in the ABOS Part II Case Lists is decreasing, we found Foot and Ankle fellowship-trained surgeons are operating on an increasing number of ATRs during their board collection period.

Level of Evidence

Level III, retrospective cohort study.

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.

Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis

Background

This systematic review and meta-analysis investigated the treatment for Achilles tendon rupture (ATR) associated with the lowest risk of rerupture in older patients.

Methods

Five databases were searched through September 2022 for studies published in the past 10 years analyzing operative and nonoperative ATR treatment. Studies were categorized as "nonelderly" if they reported only on patients aged 18-60 years. Studies that included at least 1 patient older than age 70 were categorized as "elderly inclusive." Of 212 studies identified, 28 were eligible for inclusion. Of 2965 patients, 1165 were treated operatively: 429 (37%) from elderly-inclusive studies and 736 (63%) from nonelderly studies. Of the 1800 nonoperative patients 553 (31%) were from nonelderly studies and 1247 (69%) were from elderly-inclusive studies.

Results

For nonoperative treatment, the rate of rerupture was higher in nonelderly studies (83/1000 cases, 95% CI = 58, 113) than in elderly-inclusive studies (38/1000 cases, 95% CI = 22, 58; P<.001). For operative treatment no difference was found in the rate of rerupture between nonelderly studies (7/1000 cases, 95% CI = 0, 21) and elderly-inclusive studies (12/1000 cases, 95% CI = 0, 35; P<.78). Overall, operative treatment was associated with a rerupture rate of 1.5% (95% CI: 1.0%, 2.8%) (P<.001), which was lower than the 5% rate reported by other studies for nonoperative management (P<.001).

Conclusion

Older patients may benefit more than younger patients from nonoperative treatment of ATR. More studies are needed to determine the age at which rerupture rates decrease among nonoperatively treated patients.

Level of Evidence

3.

Effectiveness of homogenized nursing care intervention in postoperative bladder irrigation of urological system in primary hospitals-Taking the incidence of postoperative complications as an example: A retrospective study

To explore the effect of homogenized nursing interventions for bladder irrigation after urological surgery in primary hospitals, and to further analyze the incidence of postoperative complications according to the different nursing methods. The experiment selected 110 patients with urological disorders who underwent bladder irrigation, and the subjects were admitted to the hospital from January 2020 to October 2023. The subjects were chronologically divided into a control group and an experimental group, with the admission time of the control group being between between January 2020 and October 2022. The experimental group was admitted between October 2022 and October 2023. Conventional nursing care and homogenized nursing care were used respectively, and the intervention effect of homogenized nursing care was assessed by comparing the patients' psychological state indexes, vital characteristic indexes, and the incidence of various postoperative complications under the 2 interventions. None of the indicators were statistically significant before the nursing intervention. In the comparison of nursing satisfaction and clinical comfort, the experimental group's nursing satisfaction was 94.5% and clinical comfort was 90.9%, which was significantly higher than that of the control group. In the comparison of the incidence of postoperative complications, the incidence of urinary retention in the experimental group was 1.82%, which was significantly lower than that of the control group. In addition, the total incidence of complications in the experimental group was 1.82%, which proved that the homogenized nursing intervention was effective in reducing the complications after urinary bladder irrigation. In multifactorial logistic regression analysis, after homogenized nursing intervention. The relative risks of the 4 complications were 1.836, 1.445, 1.993, and 2.138, respectively, which were significantly lower than those of conventional nursing intervention. In the ROC analysis, the AUC values of the 4 complications were 0.832, 0.731, 0.746, and 0.723, respectively. proving the superiority of homogenized care in preventing postoperative complications. Homogenized nursing intervention can effectively reduce the incidence of postoperative complications in patients with urological postoperative bladder irrigation, improve patients' symptoms and prognosis, and improve the quality of care and patients' quality of life.

Bilateral Acute Achilles Tendon Rupture Can Be Effectively Treated Non-operatively

Acute rupture of the Achilles tendon (AT) is a common but debilitating injury that requires immediate diagnosis and effective management. Spontaneous bilateral AT rupture is rare; however, it can lead to severe disability for a significant period. This case report presents a 76-year-old patient who suffered a bilateral AT rupture while engaging in a non-strenuous activity. Upon confirmation of the diagnosis by physical examination and radiologic evaluation, conservative treatment was decided due to the presence of numerous comorbidities. A personalized rehabilitation protocol was implemented, allowing weight-bearing activities using Achilles boots at six weeks. Healing of both ATs was confirmed by an MRI at three months. Our case shows that non-operative treatment of these injuries can result in exceptionally favorable outcomes and should not be disregarded. However, thorough patient compliance and surveillance are prerequisites.

Achilles tendon rupture primary repair technique: A comparative retrospective study between graft versus no-graft

Introduction

Achilles tendon rupture is one of the most common musculoskeletal injuries and accounts to 20 % of all large tendon ruptures The surgical choice of a procedure might play a role in the incidence of postoperative complications. This study aimed to estimate and compare the incidence of complications occurring within a 30-day window following primary surgical repair of the Achilles tendon with or without a graft.

Methods

A retrospective cohort study was conducted using the ACS NSQIP database from 2005 to 2021. Patients were divided into 2 cohorts (primary surgical repair with and without graft).

Results

A total of 7010 patients were included in the analysis. Among the graft group, 10.9 % reported any complication which was double the percentage of complications in the no graft group. Only 3.8 % of the no graft patients had reported systemic complications compared to 8.3 % in the graft group. Chronic steroid use was found to be an effect modifier in the incidence of any complications after primary surgical repair when comparing graft versus no graft (P-value 0.016).

Conclusion

Surgical repairwith tendon graft develops more complications than repairing without graft. Therefore, it is imperative for physicians to strive for an early diagnosis, as any delay in treatment significantly raises the likelihood of complications.

Levels of evidence

III, Retrospective Cohort Study.

The effect of smoking on 30-day complications following primary repair of Achilles tendon ruptures

PURPOSE

There exists a gap in the knowledge of the impact of smoking on Achilles tendon rupture repair. This study evaluates perioperative and postoperative complications associated with smoking to allow for a more informed evaluation and discussion with the patients when considering the surgical management of Achilles tendon repair in this patient population.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing Achilles tendon rupture repair from 2006 to 2019. Two patient cohorts were defined in this retrospective study: smokers and patients who did not smoke. The various patient demographics, medical comorbidities, and postoperative outcomes were compared using bivariate and multivariate analyses between the smoking and non-smoking groups.

RESULTS

Of 4209 patients who underwent Achilles tendon repair, 3662 patients (87%) did not smoke, whereas 547 patients (13%) were smokers. Patients who were smokers were more likely to be younger and have a higher body mass index. Following multivariate analyses, those who smoked had an increased risk of experiencing wound dehiscence (OR 3.57; p = 0.013) and urinary tract infections (OR 1.21; p = 0.033) compared to non-smoking patients.

CONCLUSION

Despite the rate of complications being relatively low in the short-term perioperative period, individuals who smoke should be counseled on the surgical risks they may experience following Achilles tendon repair, including wound dehiscence and urinary tract infections. Discussion preoperatively between the physician and patient who smoke can include ways in which postoperative care will be done to minimize the risk of adverse events, ultimately reducing costs for both the patient and the hospital.

Nicotine Dependence and Rates of Postoperative Complications in Achilles Tendon Repair

BACKGROUND

Nicotine is a modifiable risk factor that is well demonstrated to cause deleterious effects on tendon healing and overall health. Individuals that have a dependence on nicotine may be at an elevated risk for numerous postoperative complications when compared to nondependent patients. The purpose of this study is to evaluate the complications postoperatively between nicotine- and non-nicotine-dependent Achilles tendon repairs.

METHODS

The global health network database, TriNetX, was used to access and analyze deidentified patient information. Two cohorts were identified for the purposes of this study. Cohort A was defined as patients who had an Achilles tendon repair (Current Procedural Terminology [CPT]: 27650 or CPT: 27654) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17). Cohort B was defined as patients who had an Achilles tendon repair but did not have a dependence to nicotine. Data were gathered from health care organizations from August 21, 2000, to August 21, 2023. All postoperative complications were analyzed between 1 and 90 days after the Achilles tendon repair.

RESULTS

A total of 2117 nicotine-dependent patients were matched with 18 102 non-nicotine-dependent patients. After propensity matching for age at event, ethnicity, race, sex, and type 2 diabetes mellitus, nicotine-dependent patients who underwent Achilles tendon repair experienced higher associated risk for numerous postoperative complications. When compared to nondependent patients, nicotine-dependent patients had increased risk for wound disruption (risk ratio [RR] 1.55, 95% CI 1.11-2.16) and infection following a procedure (RR 1.64, 95% CI 1.09-2.47) within 90 days post Achilles tendon repair.

CONCLUSION

In this database study using propensity matching, nicotine-dependent patients who underwent Achilles tendon repair were correlated with an increased associated risk for wound disruption and infection after a procedure than their non-nicotine-dependent counterpart.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

An Extracellular Vesicle-Cloaked Multifaceted Biocatalyst for Ultrasound-Augmented Tendon Matrix Reconstruction and Immune Microenvironment Regulation

The healing of tendon injury is often hindered by peritendinous adhesion and poor regeneration caused by the accumulation of reactive oxygen species (ROS), development of inflammatory responses, and the deposition of type-III collagen. Herein, an extracellular vesicles (EVs)-cloaked enzymatic nanohybrid (ENEV) was constructed to serve as a multifaceted biocatalyst for ultrasound (US)-augmented tendon matrix reconstruction and immune microenvironment regulation. The ENEV-based biocatalyst exhibits integrated merits for treating tendon injury, including the efficient catalase-mimetic scavenging of ROS in the injured tissue, sustainable release of Zn2+ ions, cellular uptake augmented by US, and immunoregulation induced by EVs. Our study suggests that ENEVs can promote tenocyte proliferation and type-I collagen synthesis at an early stage by protecting tenocytes from ROS attack. The ENEVs also prompted efficient immune regulation, as the polarization of macrophages (Mφ) was reversed from M1φ to M2φ. In a rat Achilles tendon defect model, the ENEVs combined with US treatment significantly promoted functional recovery and matrix reconstruction, restored tendon morphology, suppressed intratendinous scarring, and inhibited peritendinous adhesion. Overall, this study offers an efficient nanomedicine for US-augmented tendon regeneration with improved healing outcomes and provides an alternative strategy to design multifaceted artificial biocatalysts for synergetic tissue regenerative therapies.

Return to Play Following Achilles Tendon Rupture in NFL Players Based on Position

BACKGROUND

The purpose of this study was to determine the return-to-play (RTP) rate and postinjury performance after Achilles tendon (AT) ruptures in National Football League (NFL) skill position players.

METHODS

The study included NFL skill positions with an AT rupture between the 2009-2010 and 2015-2016 seasons. Performance data were collected and compared against a matched control group. RTP was defined as playing in at least 1 game after repair.

RESULTS

RTP rate was 57% for the study cohort. The tight ends (TEs) had the highest RTP rate at 71% while the wide receivers (WRs) had the lowest RTP rate at 38%. Compared with the control group, WRs with successful RTP had significantly less receptions per game (P = .01). For defensive players with RTP there were significant decreases in postrepair performance in tackles, passes defended, and fumbles forced/recovered compared with the control group.

CONCLUSION

A total of 57% of players achieved RTP with WRs and running backs (RBs) having the lowest RTP rates and TEs and linebackers (LBs) having the highest RTP rates. RBs, defensive backs (DBs), and LBs with successful RTP had decreased performance in all categories. This updated information may be helpful for athletes, physicians, scouts, and coaches in evaluating players with a history of AT rupture.

LEVELS OF EVIDENCE

Analytic, level 3, retrospective cohort study, Epidemiologic study.

Rerupture and wound complications following Achilles tendon repair: A systematic review

Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.

Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrates improved time-zero biomechanical and promising short to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint over-constraint, nerve paresthesia, and infection.

Composite Free Tissue Transfer for Reconstruction of Lower Extremity Tendon Injuries: A Systematic Review

BACKGROUND

 Tendon rupture with extensive soft tissue loss has few reconstructive options. Composite free tissue transfers including skin and tendon offer an attractive reconstructive approach. Unfortunately, most studies discussing them come from sparse case reports. We systematically assess evidence supporting composite flap use in single-stage reconstruction of lower extremity tendon and soft tissue defects.

METHODS

 A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. OvidMEDLINEqueried for records pertaining to the study question using Medical Subject Heading (MeSH) terms such as "lower extremity," "tendon," and "composite flap." No limitations were placed on the year of publication, country of origin, or study size. Study characteristics and patient demographics were collected. Primary outcomes included:(1) defect location, composite flap characteristics;(2) return to ambulation;(3) joint range of motion;(4) patient satisfaction, and (5) complications.

RESULTS

 In total, 29 articles examining 173 patients with lower extremity tendon defects and soft tissue loss were identified. Average age was 44.3 years (SD 17.5); most patients were male (n = 110, 66.3%). Achilles defect was mostly reported (n = 151, 86.8%), followed by patellar (n = 17, 9.8%) and other tendon defects (n = 6, 3.4%). Average tendon defect size was 8.4 cm (SD 4.0), average soft tissue loss was 80.2 cm² (SD 40.0). Most employed composite flap was anterolateral thigh and fascia lata (ALT + FL) (n = 101, 58.0%). Most patients (n = 134, 99.3%) returned to ambulation in an average 123.1 days (SD 78.3). Average reconstructive joint degree of motion was 62.1 degrees compared with normal degree of motion 62.3 degrees. Patient-reported outcomes demonstrated increased satisfaction after reconstruction.

CONCLUSION

 Composite flaps effectively reconstruct a variety of tendon and soft tissue defects; the most reported flap is ALT + FL, which provides large flap territories and rapid healing in Achilles, patellar, and other tendon defects. In this review, patients with composite flaps demonstrated return to ambulation, minimal impairment in range of motion, and notable postoperative satisfaction.

A New Technique of Achilles Tendon Rupture Repaired by Double Transverse Mini-incision to Avoid Sural Nerve Injury: A Consecutive Retrospective Study

OBJECTIVE

Percutaneous suture is a classic technique used in Achilles tendon repair. However, the complication rates surrounding the sural nerve remain relatively high. Modified percutaneous repair technology can effectively avoid these complications; however, the surgical procedure is complicated. Hence, the present study was conducted to describe a redesigned repair technique for the Achilles tendon able to avoid sural nerve injury and reduce the complexity of the procedure.

METHODS

Data of patients with acute primary Achilles tendon rupture at our hospital from January 2019 to May 2020 were included. Subjects with expectations for surgical scarring underwent a minimally invasive-combined percutaneous puncture technique. The surgical time, requirement for conversion to other technologies, and length of postoperative hospitalization were investigated to assess efficacy. The American Orthopedic Foot & Ankle Society (AOFAS) score and the Arner-Lindholm scale (A-L scale) were used to assess postoperative clinical outcomes (> 24 months). During the 2-year follow-up, MRI was performed to observe the healing of the Achilles tendon. In addition, subjective satisfaction with surgical scar healing was recorded.

RESULTS

Twenty consecutive subjects with an average follow-up of 28.3 ± 4.5 months (range, 24-41) met the inclusion criteria. None of the 20 enrolled patients required a converted surgical approach. The mean surgical time was 26.9 ± 6.47 min (range, 20-44). None of the patients experienced dysesthesia or anesthesia around the sural nerve. No signs of postoperative infections were observed. MRI data showed that the wounds of the Achilles tendon healed completely in all the subjects. The AOFAS score increased from 55.6 ± 11.07 (range, 28-71) preoperatively to 97.8 ± 3.34 (range, 87-100) at the last follow-up. The A-L scale showed that 90% of the subjects (n = 18) presented as excellent and 10% of the subjects (n = 2) presented as good, with an excellent/good rate of 100%. Moreover, subjects' satisfaction for surgical scars was 9.1 ± 0.78 (upper limit, 10).

CONCLUSIONS

The results indicate that this technique can achieve good postoperative function, a small surgical incision, and high scar satisfaction. In addition, this technique should be widely used in suturing Achilles tendon ruptures.

[Reconstruction of Soft Tissue Defects of the Achilles Tendon Region: a Literature Review]

BACKGROUND

Soft tissue defects in the achilles tendon region occur after trauma, but also as a complication after open recon- struction of the tendon with subsequent infection.

OBJECTIVES

Recommendations for the treatment of soft tissue injuries involving the Achilles tendon are presented.

MATERIALS AND METHODS

A search of the German, French and English literature on reconstruction of soft tissue defects of the Achilles tendon region was performed, which were differentiated into singular and combined tendocutaneous defects. Combined defects were further subdivided into three reconstructive principles: a simple soft tissue reconstruction without tendon repair or a combined reconstruction of the soft tissue as well as the tendon using either a vascularized tendon transplant or an avascular tendon graft.

RESULTS

Local and distally-based pedicled flaps include a relatively high risk or perioperative morbidity, whereas free flaps are described with significantly lower complications rates. Therefore, the authors prefer free flaps for reconstruction. Potential donor sites are the Medial Sural Artery (MSAP-) flap for smaller defects or free fasciocutaneous or muscle flaps in patients with large defects. The standard for tendocutaneousreconstructions is the free anterolateral thigh flap including vascularized fascia. Non-vascularized tendon grafts are frequently applied from the flexor hallucis longus- or peroneus brevis tendon.

CONCLUSIONS

Reconstructions over the Achilles tendon require thin and stable reconstructions that additionally allow slippage of soft tissues. Moreover, the use of normal shoes should be possible. The postoperative strength and range of motion of the ankle joint show comparable functional results after vascularized and non-vascularized tendon reconstruction.

Effect of Platelet-Rich Plasma Augmentation on Endoscopy-Assisted Percutaneous Achilles Tendon Repair

Background: Achilles tendon ruptures are one of the most common sports injuries. Recently, platelet-rich plasma (PRP) has been widely used in tendon-related disorders to enhance tendon healing. However, studies regarding PRP treatment in Achilles tendon rupture show inconsistent results. The purpose of this study was to evaluate the effectiveness of PRP in patients with acute Achilles tendon rupture treated with endoscopy-assisted percutaneous repair. Methods: A total of 62 patients with acute Achilles tendon rupture treated with surgical repair from January 2014 to December 2018 were enrolled in this study. Surgical repair in conjunction with PRP augmentation after surgery was classified as the PRP group. Surgical repair without PRP augmentation was classified as the non-PRP group. All patients were followed up at least 2 years post-operation. The outcomes were evaluated on the basis of rate of return to sports, time to return to play, Achilles Tendon Total Rupture Score (ATRS), calf circumference ratio, ankle range of motion (ROM) and complications following surgery. Results: At 2-year follow-up, the ATRS score was not significantly different between groups (p = 0.8), but the ATRS score in both groups improved with time. Rate of return to sports and time to return to play were not different between the two groups (p = 1.00). Moreover, calf circumference ratio and ankle ROM were evaluated at 6-month, 12-month, 18-month and 24-month follow-ups. At 6 months, the PRP group had better ankle ROM (p = 0.003) and a higher calf circumference ratio (p = 0.011); however, at the 24-month evaluation, there were no between-group differences regarding calf circumference ratio, ankle dorsiflexion and plantarflexion (p > 0.05). Conclusion: We show that PRP augmentation in Achilles tendon surgery did not yield superior functional and clinical outcomes. Therefore, clinicians should inform patients of the above information when undergoing Achilles tendon surgery and offer correct expectations to family and patients regrading PRP treatment.

Locating the danger zone to avoid injury to the sural nerve during Achilles calcaneal tendon repair. A systematic review of cadaveric studies with clinical implications

INTRODUCTION

Although iatrogenic injuries to the sural nerve (SN) are commonly encountered in calcaneal (Achilles) tendon (CaT) repair surgeries, the relationship between both structures have anatomical variations. A quantitative evidence synthesis has not been yet conducted. Our systematic review aims to better define the safe zone where the SN crosses the lateral border of CaT.

METHODS

Electronic databases were searched to locate relevant anatomical studies recording details regarding the distance at which SN crosses the CaT. The Checklist for Anatomical Reviews and Meta-Analyses (CARMA) was followed. The primary outcome was the mean distance from CaT insertion to SN crossing site, to locate a safe zone. The secondary outcome was the mean horizontal distance from the SN to the CaT lateral border.

RESULTS

Seven studies met the inclusion criteria with a total of 204 cadaveric limbs. The danger zone was located 2 cm distal and proximal to the mean distance of the crossing point. The mean distance from CaT insertion to the SN crossing site was 9.91 ± 0.67 cm. The mean horizontal distance between SN and the CaT lateral border decreased from a mean of 19.8 ± 2.06 mm at the calcaneal tuberosity level to 3.6 ± 0.4 mm at 10 cm proximal to the tuberosity.

DISCUSSION

This review demonstrated that 10 cm is the average distance from the CaT insertion onto the calcaneal tuberosity to the point of crossing of the SN. A safe zone would be 2 cm away proximally and distally from the crossing point. We recommend placing the proximal lateral sutures away from this region. This finding should help surgeons avoid SN injuries during open or percutaneous approaches for calcaneal tendon rupture.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors

PURPOSE

The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture.

METHODS

A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years.

RESULTS

Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050).

CONCLUSION

The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture.

LEVEL OF EVIDENCE

III.

Achilles: Failed Acute Repair

Acute Achilles tendon ruptures are commonly managed with surgical repair. This particular surgery is prone to rerupture, wound complications, deep vein thrombosis, and sural nerve injuries. In this chapter the authors discuss complications, how to avoid them, and ultimately how to manage complications with your patients.

Achilles Tendon Repairs: Identification of Risk Factors for and Economic Impact of Complications and Reoperation

BACKGROUND

Compared with nonoperative management, Achilles tendon repair is associated with increased rates of complications and increased initial healthcare cost. However, data are currently lacking on the risk factors for these complications and the added healthcare cost associated with common preoperative comorbidities.

HYPOTHESIS

Identify the independent risk factors for complications and reoperation after acute Achilles tendon repair and calculate the added cost of care associated with having each preoperative risk factor.

STUDY DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A retrospective review of a large commercial claims database was performed to identify patients who underwent primary operative management for Achilles tendon rupture between 2007 and 2016. The primary outcome measures of the study were risk factors for (1) postoperative complications, (2) revision surgery, and (3) increased healthcare resource utilization.

RESULTS

A total of 50,279 patients were included. The overall complication rate was 2.7%. The most common 30-day complication was venous thromboembolism (1.2%). The rate of revision surgery was 2.5% at 30 days and 4.3% at 2 years. Independent risk factors for 30-day complications in our cohort included increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Independent risk factors for revision surgery within 2 years included female sex, tobacco use, hypertension, obesity, and the presence of any postoperative complication. The average 5-year cost of operative intervention was $17,307. The need for revision surgery had the largest effect on 5-year overall cost, increasing it by $6776.40. This was followed by the presence of a postoperative complication ($3780), female sex ($3207.70), and diabetes ($3105).

CONCLUSION

Achilles tendon repair is a relatively low-risk operation. Factors associated with postoperative complications include increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Factors associated with the need for revision surgery include female sex, hypertension, obesity, and the presence of any postoperative complication. Female sex, diabetes, the presence of any complication, and the need for revision surgery had the largest added costs associated with them.

CLINICAL RELEVANCE

Surgeons can use this information for preoperative decision-making and during the informed consent process.

Rates of complications in Achilles tendon rupture repair using absorbable and nonabsorbable suture material; A systematic review

BACKGROUND

The impact of suture type on tensile strength, re-rupture rates and infection risk in Achilles tendon rupture repair is not been well established. The aim of this review is to evaluate existing literature on the associated risk of postoperative infection with absorbable and non-absorbable suture materials in Achilles tendon rupture repair.

METHODS

A systematic review of search databases PubMed; Google Scholar; and OVID Medline was made to identify studies related to complications associated with Achilles tendon rupture repair. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare rupture rates and infections following rupture repair.

RESULTS

12 studies with a total of 460 patients, 230 in both nonabsorbable and absorbable suture groups were included for analysis. Risk of wound complications was significantly higher in patients with non-absorbable sutures (p < 0.001).

CONCLUSION

Nonabsorbable braided sutures is associated with the highest risk of postoperative wound complications following Achilles tendon rupture repair.

Treatment of partial injury of the calcaneus tendon with heterologous fibrin biopolymer and/or photobiomodulation in rats

The present study aimed to evaluate the new heterologous fibrin biopolymer associated, or not, with photobiomodulation therapy for application in tendon injuries, considered a serious and common orthopedic problem. Thus, 84 Rattus norvegicus had partial transection of the calcaneus tendon (PTCT) and were randomly divided into: control (CG); heterologous fibrin biopolymer (HFB); photobiomodulation (PBM); heterologous fibrin biopolymer + photobiomodulation (HFB + PBM). The animals received HFB immediately after PTCT, while PBM (660 nm, 40 mW, 0.23 J) started 24 h post injury and followed every 24 h for 7, 14, and 21 days. The results of the edema volume showed that after 24 h of PTCT, there was no statistical difference among the groups. After 7, 14, and 21 days, it was observed that the treatment groups were effective in reducing edema when compared to the control. The HFB had the highest edema volume reduction after 21 days of treatment. The treatment groups did not induce tissue necrosis or infections on the histopathological analysis. Tenocyte proliferation, granulation tissue, and collagen formation were observed in the PTCT area in the HFB and HFB + PBM groups, which culminated a better repair process when compared to the CG in the 3 experimental periods. Interestingly, the PBM group revealed, in histological analysis, major tendon injury after 7 days; however, in the periods of 14 and 21 days, the PBM had a better repair process compared to the CG. In the quantification of collagen, there was no statistical difference between the groups in the 3 experimental periods. The findings suggest that the HFB and PBM treatments, isolated or associated, were effective in reducing the volume of the edema, stimulating the repair process. However, the use of HFB alone was more effective in promoting the tendon repair process. Thus, the present study consolidates previous studies of tendon repair with this new HFB. Future clinical trials will be needed to validate this proposal.

Long Term Follow-up of Composite Flaps for Single-stage Reconstruction of Concomitant Tendon and Soft Tissue Defects

Tendon rupture in the setting of significant soft tissue loss poses a challenging reconstructive situation, which requires (1) recreating a stable gait cycle, (2) reducing shear forces and re-rupture risk, and (3) providing adequate soft tissue coverage. In this study, we outline our experience with composite flaps in single-step reconstruction of various lower extremity tendinous injuries with soft tissue loss.

Methods

A retrospective review of all patients requiring free tissue transfer at our tertiary wound care center between 2011 and 2020 was performed. Patients undergoing single-stage free tissue transfer for both soft tissue coverage and tendon reconstruction were selected. Variables of interest included demographics, comorbid conditions, baseline functionality, reconstructive details, and wound characteristics. Outcomes of interest were flap success, return to ambulation, time to ambulation, and postoperative complications.

Results

Nineteen patients were included in this study. Patients were on average 48.0 years old (SD 16.5), with a median Charlson Comorbidity Index of 1.00 (IQR: 0.0-2.5). Defects were most often on the ankle (n = 1 3, 68.4%), with extension to the foot or leg in six of these cases. Median wound size was 68.0 cm² (IQR: 48.0-120.0). The most common tendon requiring reconstruction was the Achilles (n = 13, 68.4%). An anterolateral thigh flap with attached fascia lata extension rolled into a neotendon was used in all 19 cases. At baseline, all patients were ambulatory. Only one patient (5.3%) required return to the operating room for suspected vascular compromise. At a median of 14.4 months (IQR: 8.5-40.5), all 19 patients were ambulatory.

Conclusions

Simultaneous reconstruction of tendinous injuries and soft tissue defects can be readily achieved via composite free flaps. Although other methods of reconstruction can be considered for smaller soft tissue and tendon loss, this approach has significant utility for patients with large defects and yields robust return to preinjury functionality.

Delayed Onset of Infectious Foreign Body Granuloma for Nonabsorbable Sutures After Open Achilles Tendon Repair: A Case Report

Foreign body granulomas from sutures are more common among non-absorbable sutures compared to absorbable sutures and have been reported as a postoperative complication in a variety of medical fields. However, only a few cases of delayed foreign body reaction have been reported and addressed with orthopedics. We present a patient with systemic lupus erythematosus who developed an infectious suture granuloma that extended to the entire Achilles tendon and was induced by nonabsorbable sutures that were used for open Achilles tendon repair 20 years before. This granuloma was resistant to antibiotic treatment and drainage and required surgical intervention. The tumor was marginally resected, and the continuity of the Achilles tendon was preserved. Histopathological examination detected many suture materials surrounded by xanthochromic necrotic lesions and the lesion was diagnosed as a foreign body granuloma. At 1 year after the operation, the patient did not exhibit exacerbation of infection or recurrence of the tumor, and she became able to walk by herself. To the best of our knowledge, this represents the first report of an infectious delayed foreign body granuloma in autoimmune disorder patient after open Achilles tendon repair. Surgical intervention should be considered, as treatment with conservative therapy such as antibiotics may be difficult.

What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence.

QUESTIONS/PURPOSES

We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery?

METHODS

This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar.

RESULTS

We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes.

CONCLUSION

Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Acute Achilles Tendon Rupture Repair in Athletically Active Patients: Results on 188 Tendons

We report on the outcome of acute Achilles tendon ruptures by a single surgeon using open and percutaneous techniques was performed. This prospective study included 186 patients with 188 ruptured Achilles tendons. A traditional open technique was primarily performed on patients from January 2001 to December 2011. From January 2012 to January 2018, a percutaneous repair was primarily performed. Outcome measures included the Roles and Maudsley (RM) score, ability to perform a single leg heel raise, calf atrophy and return to activity. There were 149 males (average age 42.5 ± 12.7 years) and 39 females (average age 41.7 ± 11.4 years). Of the 188 ruptured tendons (92 repairs on the right Achilles and 96 on the left), 103 were repaired percutaneously and 85 had open repairs. There were 18 (9.6%) complications. Three re-ruptures occurred, one following open and two following percutaneous repairs, all within 12 weeks of the original repair. Two patients developed a Venousthromboembolism (1.0%). Thirteen patients had suture reactions; three infections (1.6%), 11 wound complications (5.8%), and 3 required surgical excision of the suture material (1.6%). Non-absorbable sutures were associated with more wound complications and were more frequently used in open repairs (p = .003). Patients who underwent open repair experienced more wound complications (p = .0001). Patients who underwent percutaneous repair using absorbable suture experienced a lower rate of overall complications (p = .0007). Basketball (n = 29) was the most common sport during which ruptures occurred. Return to activity (RTA) was 8.2 ± 2.9 months. There was no difference for RTA between males and females (p = .54) and RM scores (p= .69), nor surgical technique, and no difference for RTA based on the desired activity (p = .47). 123 of the 188 patients returned to their desired activity (65.5%). There was a statistically significant evidence of a positive association between inability to perform heel-raises and decreased activity (p = .01).

The Fragility of Statistical Findings in Achilles Tendon Injury Research: A Systematic Review

Probability analysis with the reporting of P values is often used to determine the statistical significance of study findings in the Achilles literature. The purpose of this study was to determine the utility of applying a fragility analysis to comparative trials evaluating Achilles tendon injuries.

Endoscopic reconstruction for chronic Achilles tendon ruptures using a hamstring tendon autograft

BACKGROUND

To determine the safety and efficacy of endoscopic reconstruction of chronic Achilles tendon ruptures using a hamstring tendon autograft at mid-term follow-up.

METHODS

We reviewed the medical records of patients with chronic Achilles tendon rupture treated surgically by endoscopic reconstruction using a hamstring tendon autograft at our institution between March 2010 and October 2015. Radiologic outcomes were assessed using pre- and postoperative magnetic resonance imaging (MRI). Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Plantar Flexion Strength (PFS), the Victorian Institute of Sport Assessment-Achilles (VISA-A) scale, the Visual Analogue Scale (VAS) pain score, and the Arner-Lindholm standard. All patients achieved primary healing with no lengthening of the Achilles tendon, skin necrosis, infection, deep vein thrombosis or other complications.

RESULTS

Mean follow-up period was 15 ± 3 months (range, 12-18 months). There was no Achilles tendon re-rupture. MRI examination revealed that Achilles tendon continuity was restored. Patients' mean AOFAS, PFS, and VISA-A scores were significantly higher and mean VAS pain score was significantly lower after surgery compared to before (P < 0.05). According to Arner-Lindholm standards, there were twenty (76.9%) excellent, six (23.1%) good, and zero bad outcomes.

CONCLUSION

Endoscopic reconstruction utilizing a hamstring tendon autograft is a safe and efficacious option for repair of chronic Achilles tendon ruptures. Studies with larger sample sizes and a longer follow-up are required to confirm the advantage of this technique compared to open surgery.

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.

Predisposing Factors for 30-Day Complications Following Achilles Tendon Repair

Certain risk factors for Achilles tendon repair complications, including tobacco use, diabetes mellitus, steroid use, and obesity, have been well-reviewed. This study analyzes the impact of a range of demographic factors on unique surgical complications within the 30-day postoperative period. We extracted data from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2017 and searched for Achilles tendon repairs using CPT codes 27650, 27652, and 27654, identifying 4,040 patients. Twenty-two demographic variables and their association with each of 4 complications were analyzed using t tests or chi-squared tests. A logistic regression was conducted to determine independent risk factors for each outcome, based on results from the bivariate analyses. Variables having p <.2 on bivariate analysis were included in the multivariate analysis of the corresponding surgical complication. Patients with open or infected wounds preoperatively were more likely to return with a postoperative surgical infection (p< .001). Likewise, each additional year of the patient's age increased their likelihood of developing a surgical infection (p= .03). Patients with "clean/contaminated" wound sites prior to repair were more likely to return for an additional service (p= .02). Furthermore, each additional inch of the patient's height (p= .03) and every additional minute of operative time increased a patient's risk of developing a new-onset deep vein thrombosis (p= .01). This study offers providers a more complete picture of which preoperative characteristics affect Achilles tendon repair patients, directing management to reduce postoperative complication rates.

Fibrin biopolymer sealant and aquatic exercise association for calcaneal tendon repair

PURPOSE

The aim of this work was to analyze the effect of fibrin biopolymer sealant (FS) associated or not to aquatic exercise (AE) on the calcaneal tendon repair.

METHODS

Forty-four female Wistar rats were randomly divided into four experimental groups: Lesion control (L), Lesion and FS (LS), Lesion and AE (LE) and Lesion and FS associated to AE (LSE). The edema volume (EV), collagen ratio, and histopathological analysis were evaluated after 7, 14, and 21 days of partial tendon transection.

RESULTS

The EV was statistically reduced for all treatment groups after 7 and 21 days when compared to L group. The LS and LSE had the highest EV reduction after 21 days of treatment. The FS group didn't induce tissue necrosis or infections on the histopathological analysis. It was observed tenocytes proliferation, granulation tissue and collagen formation in the tendon partial transection area in the FS group. The LSE demonstrated higher amount of granulation tissue and increased the collagen deposition at the injury site.

CONCLUSIONS

Our data suggests that the therapeutic potential of the association of heterologous fibrin biopolymer sealant with aquatic exercise program should be further explored as it may stimulate the regeneration phase and optimize calcaneal tendon recovery.

Endoscopic Surgery for Delayed Wound Healing After Achilles Tendon Suture Repair: A Report of Three Cases

Background

Delayed wound healing is a potention complication after Achilles tendon suture repair and occurs for various reasons. The conventional treatment for delayed wound healing is open surgery, but patients face long recovery times and postoperative care is difficult.

Case Presentation

This report presents three patients who were seen at our institute from April 2008 to October 2017 due to long‐term non‐healing wounds after surgery. All three patients had undergone surgery at least 2 months previously. We performed endoscopic surgery on these patients. After the operation, patients received less antibiotics and simpler care than would be required for conventional open surgery. There is no need to keep the wound open after the operation or perform wound cleaning for multiple times at the same time, which can reduce healing time. At the last follow up, all postoperative scores among the patients were significantly improved compared to before surgery. The Achilles tendon total rupture scores were excellent and the American Orthopedic Foot and Ankle Society scores were satisfactory, indicating improvements in Achilles tendon function and movement in patients after surgery.

Conclusion

Our case reports demonstrate that arthroscopic treatment for delayed wound healing after Achilles tendon suture repair is satisfactory and reliable; frequent opening of the wound for cleaning is not required after the operation, thus reducing the healing time.

[A new method of surgical treatment of patients with chronic distal Achilles tendon rupture]

OBJECTIVE

To improve postoperative outcomes in patients with distal Achilles tendon rupture by using of a new method of surgical treatment.

MATERIAL AND METHODS

The authors proposed a new method to restore the Achilles tendon for its distal rupture (within 2 cm from attachment to the calcaneus). This approach implies forming a canal in the calcaneus and minimally invasive harvesting of the plantar tendon. At the next stage, the plantar tendon is passed through the canal of the calcaneus in U-shaped fashion and proximal part of Achilles tendon with maximum approximation of its fragments and imposing of interrupted sutures on the plantar and Achilles tendons to hold the position. The end of plantar tendon is used to reinforce damaged area. The schemes and surgical stages are shown in the figures. We reported a patient with distal Achilles tendon rupture and postoperative outcome.

RESULTS

An above-mentioned approach was applied in 26 patients. The control group consisted of 21 patients who underwent recovery with anchor fixers. Early and long-term postoperative results, as well as adverse events were analyzed in both groups. Biomechanical parameters of gait were evaluated from the standpoint of evidence-based medicine using podography and functional myography. We confirmed an advantage of treatment in the main group.

Higher pyruvate levels after Achilles tendon rupture surgery could be used as a prognostic biomarker of an improved patient outcome

PURPOSE

The primary aim of this study was to assess the relationship between the metabolites lactate and pyruvate in the healing tendon after Achilles tendon rupture (ATR) and patient-reported outcome at 6 and 12 months. A secondary aim was to evaluate which underlying factors regulate lactate and pyruvate concentrations.

METHODS

Lactate and pyruvate concentrations were measured two weeks post-operatively in both the healing- and healthy Achilles tendon in 109 patients (90 men, 19 women; mean age 40 ± 7.9 years). Patient demographics, degree of physical activity, timing of surgery, operation time, patient-reported loading and step counts were investigated in relation to metabolite concentrations. At 6 and 12 months, the Achilles tendon Total Rupture Score (ATRS) questionnaire was used to assess patient outcome.

RESULTS

The mean number of steps taken during the post-operative days 1-10 was the only factor significantly related to the mean concentration of lactate (R² = 0.34, p = 0.038), and pyruvate (R² = 0.46, p = 0.006). Pyruvate was demonstrated as the only factor significantly associated with ATRS at both 6 months (R² = 0.32, p = 0.003) and at 12 months (R² = 0.37, p = 0.004) using multiple linear regression.

CONCLUSION

The mean concentration of pyruvate during early ATR healing may predict patient outcome at 6 and 12 months post-operatively and possibly be used as a biomarker of healing. Early mobilization with an increased number of steps taken is an important clinical strategy to improve the metabolite concentrations during healing.

LEVEL OF EVIDENCE

III.

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.

[Clinical analysis of autogenous tendon reconstruction under total arthroscopy in treatment of chronic Achilles tendon rupture]

Objective

To investigate the effectiveness of autogenous tendon reconstruction under total arthroscopy in the treatment of chronic Achilles tendon rupture.

Methods

Between June 2015 and June 2018, 16 patients with chronic Achilles tendon ruptures were treated by autogenous tendon reconstruction under total arthroscopy. Of the 16 patients, 11 were males and 5 were females. Their mean age was 40.7 years (range, 21-55 years). The disease duration was 14-20 months (mean, 16.4 months). Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 41.2±2.2 and the pain visual analogue scale (VAS) score was 7.9±1.2. MRI and B-ultrasonography examinations showed that the Achilles tendon was not continuous. The length of Achilles tendon defect was 5.0-10.3 cm, with an average of 5.8 cm. The rupture of the Achilles tendon happened on top of the insertion of the tendon in 4 cases and at the tendon-muscle belly connection in 12 cases. The operation time, intraoperative blood loss, hospital stay, and related complications were recorded. The AOFAS score and VAS score were used to evaluate the improvement of ankle joint function and pain.

Results

The average operation time was 77.2 minutes (range, 60-90 minutes). The average intraoperative blood loss was 20.5 mL (range, 15-30 mL). The average hospital stay was 7.2 days (range, 5-10 days). All incisions healed by first intention. There was no skin necrosis, infection, or deep vein thrombosis. All the patients were followed up 8-18 months, with an average of 12 months; and 10 cases were followed up more than 12 months. During the follow-up, there was no Achilles tendon re-rupture, and the symptoms of pain and heel lifting failure significantly improved. MRI reexamination showed that the continuity of Achilles tendon recovered. At 1, 3, 6, and 12 months postoperatively, AOFAS scores significantly improved and VAS scores significantly reduced, except for 1 month postoperatively, the scores at other time points were superior to that before operation, the differences were significant ( P<0.05).

Conclusion

Autogenous tendon reconstruction under total arthroscopy in the treatment of chronic Achilles tendon rupture has the advantages of small trauma, rapid functional recovery, and satisfactory surgical efficacy.

WITHDRAWN: RNA binding protein QKI5 accelerates tenogenic differentiation and promotes tendon healing through AKT-mTOR signalling by stabilizing MALAT1

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