Biomechanical Comparison of Nonlocked Minimally Invasive and Locked Open Achilles Tendon Simulated Rupture Repairs

A comparative biomechanical study of the krackow suture technique with three common percutaneous suture techniques in the treatment of Achilles tendon ruptures

BACKGROUND

The aim of this study was to compare the biomechanical resistance under tensile forces of the Krackow suture technique with the frequently used Dresden, Carmont & Maffulli, and Ma & Griffiths percutaneous repair techniques in bovine models of Achilles tendon rupture.

METHODS

Transverse Achilles tendon rupture models were created from 4 cm proximal of the calcaneal insertion point in a total of 20 bovine Achilles tendon specimens. These were randomly allocated to 4 groups and repaired with configurations appropriate to the Dresden, Carmont & Maffulli, Ma & Griffiths and Krackow techniques. Failure mechanisms were recorded with force values (as Newton units) creating a 5 mm gap and load to failure under tensile loading at a rate of 10 mm/sec in a static testing device.

RESULTS

In the Dresden technique group, the force required for a 5 mm gap was mean 41.21 ± 13.19 N and for load to failure, mean 193.83 ± 30.16 N, which were evaluated as statistically significantly higher than in the other techniques (p < 0.05). The lowest values were determined in the Ma & Griffiths technique group (5 mm gap: 11.06 ± 8.12 N, load to failure: 97.73 ± 29.60 N) but these were not significantly lower than the values in the Krackow and Carmont & Maffulli technique groups (p > 0.05).

CONCLUSION

The results of this study showed that the Dresden technique was biomechanically superior against tensile forces compared to the Krackow technique, and the other frequently used percutaneous techniques of Carmont & Maffulli and Ma & Griffiths.

Open and Percutaneous Approaches Have Similar Biomechanical Results for Primary Midsubstance Achilles Tendon Repair: A Meta-analysis

Purpose

To evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair.

Methods

A systematic review of original research articles was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. To qualify for study inclusion, articles were required to be published in English, use a laboratory design using either human or animal tissue, and directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique with percutaneous repair using either a locking or nonlocking suture construct. The biomechanical outcomes evaluated were displacement (millimeters) and load to failure (Newtons).

Results

Twelve studies met inclusion criteria, including 234 specimens (open: 97, percutaneous locking: 73; percutaneous nonlocking: 64) that underwent primary midsubstance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (P = .240) or load to failure (P = .912) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (P = .109) between the locking and nonlocking tendon repair systems.

Conclusions

The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary midsubstance Achilles tendon repair.

Clinical Relevance

In clinical studies, similar rerupture rates have been observed after open or percutaneous Achilles tendon repair. It may be beneficial for surgeons to understand whether biomechanical differences exist between these repair techniques.

All-inside endoscopic semiautomatic running locked stitch technique shows favourable outcomes for acute Achilles tendon ruptures

PURPOSE

The safety and reliability of endoscopic Achilles tendon rupture repair are still concerning aspects. This study's aim is to evaluate an all-inside endoscopic semiautomatic running locked stitch (Endo-SARLS) technique.

METHODS

Forty cases with acute Achilles tendon rupture were treated with the all-inside Endo-SARLS technique between 2020 and 2021. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semiautomatic flexible suture passer. The threads of the high-strength suture were grasped through the paratenon subspace and then fixed into calcaneal insertion with a knotless anchor. Magnetic resonance imaging (MRI), surgical time and complications were assessed. Achilles Tendon Total Rupture Score (ATRS), Achilles Tendon Resting Angle (ATRA) and Heel Rise Height Scale (HRHS) were utilised to evaluate final outcomes.

RESULTS

The average follow-up time was 25.4 ± 0.4 (range: 24-32) months. Appropriate tendon regeneration was observed on MRI after 12 months. At the final follow-up, the median value of ATRS score was 95 (interquartile range: 94, 98). Furthermore, there is no significant difference between the injured and contralateral side in the average ATRA (18.2 ± 1.8 vs. 18.3 ± 1.9°, ns) and median value of HRHS [14.5 (13.3, 15.5) vs. 14.8 (13.5, 15.6) cm, ns]. No infection and nerve injuries were encountered. Thirty-nine patients reported that they resumed casual sports activity after 6 months. One patient had a slight anchor cut-out, due to an addition injury, which was removed after 5 months.

CONCLUSIONS

An all-inside Endo-SARLS technique showed promising clinical results for acute Achilles tendon ruptures. This procedure reduces the risk of sural nerve injuries while establishing a reliable connection between the tendon stumps.

LEVEL OF EVIDENCE

Level IV.

Modified Dresden Technique With a Distal Locking Suture for Achilles Tendon Repair: Technique Tip

[Formula: see text].