Proximal and Distal Failure Site Analysis in Percutaneous Achilles Tendon Rupture Repair

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 Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.

The modified mini-open technique for repairing total ruptured Achilles tendon using fiber wire with calcaneal fixation. A prospective case series

Background

The purpose of this study was to evaluate clinical outcomes and complications of our modified Maffuli's mini-open technique for repairing acute Achilles tendon rupture using fiber wire and calcaneal fixation.

Material and methods

Between January 2017 and August 2020, 21 patients with acute rupture of the Achilles tendon who underwent the modified mini-open Maffulli's procedure have been enrolled in the study.

Result

All surgical incisions healed well without scar adhesions or infections. One year postoperatively, the ATRS score and AOFAS score were 91.2 ± 1.8; 97.2 ± 1.6 respectively; the range of ankle joint movement was normal. Patients could return to their work and their light sporting activities at the time of 16.9 ± 1.1 weeks and 19.7 ± 0.9 weeks postoperatively, respectively. 21 out of 21 patients were able to perform single heel raise. There were no sural nerve injuries, re-ruptures, tendon elongation, or deep vein thromboses.

Conclusion

We have shown that the modified Maffulli's technique using fiber wire with a calcaneal fixation for repairing acute Achilles tendon ruptures to be a safe and reliable method without requiring specialized or expensive materials. It allows a durable repairing, a limitation of healing problems, and a quick return to physical therapy and full activity. This technique can be widely employed in a low-income country.

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The best treatment for acute Achilles tendon rupture is not defined.

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The modified Maffulli's technique using fiber wire with a calcaneal fixation is a safe and reliable method.

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It allows durable repairing, a limitation of wound healing problems, and a quick return to physical therapy.

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This technique can be widely employed in a low-income country.

Biomechanical Evaluation of Achilles Tendon Midsubstance Repair: The Effects of Anchor Angle and Position

BACKGROUND

The percutaneous knotless repair technique for Achilles tendon ruptures utilizes a Percutaneous Achilles Repair System (PARS) device for suturing the proximal tendon and 2 suture anchors for fixing the sutures into the calcaneus. Determining the best position of the suture anchors may optimize the strength of this repair.

METHODS

Twelve pairs of human ankle cadaveric specimens were randomly assigned to receive suture anchors placed at 45°, 90°, or 135° from the sagittal plane. The anchors were tensioned according to a protocol representing progressive, postoperative rehabilitation. Load, number of loading cycles, displacement, and mode of failure were recorded.

RESULTS

With the anchors placed at 45°, 90°, and 135°, the ultimate failure loads were mean 265 ± 64 N, 264 ± 75 N, and 279 ± 40 N, and the total number of loading cycles were mean 459 ± 166, 466 ± 158, and 469 ± 110, respectively. The effect of anchor angle on failure load, number of loading cycles, and displacement was not statistically significant. Visually, the anchors at 45° and 90° demonstrated sutures cutting through the bone.

CONCLUSION

We found no statistically significant difference in pullout strength between the 3 different anchor angles. Sutures cutting through the bone may be a concern with acute anchor angles. This suggests that a 135° anchor angle may result in a lower risk of tendon elongation with the percutaneous knotless repair technique.

LEVELS OF EVIDENCE

Cadaveric laboratory study.

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.

Achilles Tendon Rip-Stop SpeedBridge Repair

Achilles tendon injuries have been on the rise secondary to our increased participation in sports, increase in societal obesity rates, and the growing elderly population. There has been disagreement in recent years about whether to treat injuries such as Achilles tendon ruptures operatively or nonoperatively with aggressive functional rehabilitation. For those opting to surgically manage Achilles tendon ruptures, insertional Achilles tendonitis, or augment the described SpeedBridge Achilles tendon repair, we propose a modified rip-stop technique. The goal of this technique is to provide a biomechanical advantage to our current operative interventions for these injuries, a greater load-to-failure and a speedier, more reliable return to sport in our athletic populations.

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.

Achilles Tendon Lesions - Part 2: Ruptures

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

Mini-Open Achilles Tendon Rupture Repair

Background

We present a mini-open Achilles tendon rupture repair technique, which does not open the paratenon and avoids the sural nerve. We perform it to recover the normal working length of the gastrocnemius-soleus complex musculotendinous unit as well as possible, trying to avoid soft-tissue complications.

Description

This repair is performed via a 3-cm-long incision that is placed 4 cm proximal to the Achilles tendon gap. Through this incision, the interval between the superficial fascia of the leg and the paratenon is developed. Distally, 2 small incisions are made in order to introduce into the calcaneus 2 bone anchors loaded with nonabsorbable sutures. These sutures are retrieved from the distal attachment site through the interval between the fascia and the paratenon with specifically designed suture passers, and obtained through the proximal incision. The sutures are then woven through the proximal stump of the Achilles tendon, the first ones in a Bunnell and the last ones in a crisscross manner, recovering the physiological equinus of the ankle¹. The fascia and skin are closed appropriately.

Alternatives

Percutaneous surgical repair techniques.Open surgical repair techniques.Orthopaedic nonoperative treatment.

Rationale

This surgical technique differs from other available mini-open techniques in that it respects the rupture hematoma, accessing the tendon far from the rupture site; it does not violate the paratenon; and because of the placement in a safe anatomical interval, it does not injure the sural nerve. Because of the mini-open approach of the technique, soft-tissue complications are rare, and thus indications for this technique can be expanded over those of open surgical techniques.

Expected Outcomes

Patients can expect a nearly complete recovery of gastrocnemius-soleus function, after an appropriate rehabilitation period. Soft-tissue complications are rare, and therefore early rehabilitation can be performed. The rehabilitation lasts for 5 months to achieve a high level of physical function. A low rerupture rate (2%) can also be expected². The average return to work is 56 days.

Important Tips

Try to operate within 10 days of the rupture to avoid scar formation at the rupture site.Plan the surgical procedure according to the level of the rupture in order to ensure the suture passers are long enough to span the rupture site from the proximal incision up to the calcaneus.Ensure the bone anchors are placed in the middle of the total height of the calcaneus, avoiding the enthesis, and align the anchors to be perpendicular to the axis of the calcaneus.Follow the proximal suturing technique in order to obtain the best resistance of the repair. Taking care not to overtighten consecutive sutures, restore the appropriate level of physiological equinus.