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Lerch RJ, Gulati A, Highlander PD. Revision of Subtalar Joint Arthrodesis: Considerations for Bone Grafting, Fixation Constructs, and Three-Dimensional Printing. Clin Podiatr Med Surg 2023; 40:633-648. [PMID: 37716742 DOI: 10.1016/j.cpm.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Subtalar joint arthrodesis is a commonly used procedure for numerous pathologic conditions in the foot and ankle. Although rarely performed in isolation, this procedure can provide successful resolution of various lower-extremity complaints. There are traditional approaches to isolated subtalar joint arthrodesis; however, when these fail, the authors recommend alternatives to enhance the success of revisional surgery. These include the use of intramedullary nailing, larger harvest of autograft, and metallic wedge.
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Affiliation(s)
- Ryan J Lerch
- The Reconstruction Institute, The Bellevue Hospital, 1400 West Main Street, Bellevue, OH 44811, USA
| | - Amar Gulati
- Progressive Feet, 611 South Carlin Springs Road, Suite 508, Arlington, VA 22204, USA
| | - Peter D Highlander
- The Reconstruction Institute, The Bellevue Hospital, 1400 West Main Street, Bellevue, OH 44811, USA.
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Nakajima K. Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review. World J Orthop 2023; 14:369-378. [PMID: 37377992 PMCID: PMC10292061 DOI: 10.5312/wjo.v14.i6.369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/26/2023] [Accepted: 05/09/2023] [Indexed: 06/19/2023] Open
Abstract
Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.
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Affiliation(s)
- Kenichiro Nakajima
- Center for Foot and Ankle Surgery, Department of Orthopedic Surgery, YashioCentral General Hospital, Yashio-shi 340-0814, Saitama, Japan
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Kar S, Sauarbh S, Digge VK. Double row reconstruction of achilles tendon (speedbridge technique) for haglund syndrome results in early weight bearing. J Orthop 2023; 39:70-74. [PMID: 37125015 PMCID: PMC10130069 DOI: 10.1016/j.jor.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 05/02/2023] Open
Abstract
Background Reconstruction of tendoachilles (TA) tendon using double row reconstruction (speedbridge technique) following excision of haglund deformity is relatively newer technique. The purpose was to assess the clinical outcome and effects of early postoperative mobilization with speedbridge technique. Methods This was a prospective observational study performed between January 2018 to February 2019. All the patients underwent open excision of haglund deformity after complete detachment of TA tendon. Reconstruction of TA tendon was done using fibretape and 4.75 mm biocomposite Swivelock [ArthrexAchilles SpeedBridge Convenience Pack (AR-8928 BC-CP)].Clinical evaluation was done using American Orthopedic Foot and Ankle Society (AOFAS) Hind Foot Score (HFS) and Visual Analogue Scale (VAS). Patients were followed at 6weeks, 6 months,12 months,18 months and 2 years. Results 11 female and 2 male patients (16 feet) with mean age of 53.00 ± 4.93 years were analyzed. Full weight bearing mobilization was started on an average of 10 days postoperatively.The mean postoperative HFS, at 24 months of postoperative period, was 87.61 ± 4.69 compared to mean preoperative HFS of 53.07 ± 5.93. Conclusion Haglund deformity excision and reconstruction of Tendoachilles using double row technique is an agile construct for early mobilization with an excellent clinical outcome.
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Affiliation(s)
- Santanu Kar
- Dept of Orthopedics, K24,Green Park Extension, 110016, New Delhi, India
| | - Suman Sauarbh
- Dept of Orthopedics, Room no 73, Hostel no 8, All India Institute of Medical Sciences, 110029, New Delhi, India
| | - Vijay kumar Digge
- Dept of Orthopedics, Additional professor Room no 3096, 3 rd floor, Teaching Block, India
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Sanchez TC, Sankey MT, Willis CB, Young SM, Harrelson A, Shah A. Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position. JBJS Essent Surg Tech 2023; 13:e21.00070. [PMID: 38274278 PMCID: PMC10807889 DOI: 10.2106/jbjs.st.21.00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Background The mini-open approach with supine patient positioning is a useful technique to consider for acute Achilles rupture repair, ideally performed within 2 weeks from the time of injury. The traditional surgical approach is completed with the patient in the prone position with an extensile midline incision. Here we describe a mini-open approach with supine positioning that utilizes a single incision measuring approximately 3 to 4 cm in length and avoids the pitfalls of prone positioning, which include greater operative time and potential difficult airway management, vision loss, and brachial plexus palsies1. Description When positioning the patient supine, lower-extremity bolsters are placed beneath the contralateral hip and the operative ankle in order to allow for exaggerated external rotation of the ankle and improved medial visualization. A thigh tourniquet is then applied on the operative side in a standard sterile fashion.After appropriate draping, begin by palpating the tendon rupture site and mark a 3 to 4-cm incision line just medial to the tendon. Sharp dissection through the skin to the level of the paratenon is then performed. Incise the paratenon with a knife, separate the paratenon from the underlying Achilles tendon with a Freer elevator or scissors, subsequently remove any hematoma formation, and cut the paratenon proximally and distally with scissors or a knife. Debride any damaged tendon thoroughly.The steps of the procedure are performed under direct visualization. If the sural nerve is encountered, it is noted and retracted, and extra care is taken to avoid damaging it with instruments or suture.Now that the proximal and distal ends of the Achilles tendon are free, utilize a 4-stranded double Krackow locking stitch with two #2 FiberWires (Arthrex) on both the proximal and the distal stump. The stumps of the ruptured tendon are approximated by tying the free suture ends together with use of a simple surgeon's knot. A running epitendinous repair is performed with use of number-0 Vicryl (Ethicon) suture in a cross-stich weave technique to provide additional strength to the repair. Finally, test the integrity of the repair via an intraoperative Thompson test. The postoperative protocol includes non-weight-bearing with the operative limb in a posterior splint for 2 weeks. At the 2-week follow-up, stitches are removed and the limb is placed in a tall CAM (controlled ankle motion) walker boot with 2 heel wedges measuring 6.35 mm (0.25 inches) apiece. The patient can begin partial weight-bearing with crutches at 2 weeks postoperatively. At 4 weeks postoperatively, 1 heel wedge is removed, and at 6 weeks postoperatively, the second heel wedge is removed. Patients are instructed to begin gentle range-of-motion exercises at 2 weeks, with formal physical therapy scheduled to begin at 6 weeks. Most patients are out of the boot at 8 to 10 weeks postoperatively. Alternatives Nonoperative treatment of Achilles rupture includes functional bracing or casting with the foot resting in the equinus position and early weight-bearing and rehabilitation. As mentioned earlier, the traditional operative approach with prone positioning is a viable option but is associated with a higher incidence of procedural and anesthesia-related complications, as well as potentially increased cost1. Rationale Recent studies have shown that a mini-open approach will produce a repair that is comparable with the traditional open approach, while also minimizing the anesthesia and postural complications associated with prone positioning1. Previous studies focusing on supine positioning have generally utilized a larger incision more comparable with that of the traditional prone approach6. Other studies have utilized a minimally invasive approach but require >1 incision and often utilize specialized instrumentation, which may limit the technique to certain facilities7. The technique described in the present article utilizes a single 3 to 4-cm incision that requires no specialized instrumentation, has a minimal learning curve, and can be performed at any facility. Expected Outcomes McKissack et al. demonstrated that the overall complication rate of the mini-open supine approach (7.7%) was lower than that of the traditional prone approach (9.3%), while the average cost of the prone approach exceeded that of the supine approach by $1,8231. This increased cost, although not significant, may be attributable to longer operating room and post-anesthesia care unit times. Additionally, no patient in either cohort experienced tendon rerupture within the first year after repair, further proving the effectiveness of this technique. We have utilized this mini-open supine technique for acute Achilles ruptures for over 9 years now, with good patient outcomes and satisfaction. Throughout this duration we have not had a single patient experience rerupture of the repaired tendon. In our experience, we find this technique to be effective, with fewer complications than prone positioning. Additionally, this approach may be associated with decreased financial and anesthesia burdens. Important Tips Always palpate the tendon rupture site to determine the best incision placement.With ruptures close to the tendon insertion site, it can be notoriously difficult to mobilize the distal tendon stump, so extended incisions may be required.Test the integrity of the repair with use of the intraoperative Thompson test.This technique does not utilize any special equipment and thus can be performed at any facility.This supine approach decreases operating room turnover time, anesthesia burden, and complications associated with prone positioning. Acronyms & Abbreviations AP = anteroposteriorMRI = magnetic resonance imagingUS = ultrasoundDVT = deep vein thrombosisVAS = visual analog scaleNWB = non-weight-bearingCAM = controlled ankle motionPWB = partial weightbearingROM = range of motionPT = physical therapyOR = operating room.
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Affiliation(s)
| | | | - Chad B. Willis
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean M. Young
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Alex Harrelson
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashish Shah
- University of Alabama at Birmingham, Birmingham, Alabama
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Rein S, Kremer T. [Reconstruction of Soft Tissue Defects of the Achilles Tendon Region: a Literature Review]. HANDCHIR MIKROCHIR P 2022; 54:464-474. [PMID: 35732189 DOI: 10.1055/a-1794-5449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Susanne Rein
- Städtisches Klinikum Sankt Georg Leipzig, Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum
| | - Thomas Kremer
- Städtisches Klinikum Sankt Georg Leipzig, Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum
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Abstract
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.
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McKissack H, McLynn R, Pitts C, Alexander B, Jones J, Andrews NA, Littlefield ZL, Shah A. Safety and Efficacy of Achilles Repair Using the Mini-Open Approach in Supine Versus Prone Position: A Retrospective Study. Cureus 2021; 13:e17564. [PMID: 34646620 PMCID: PMC8480360 DOI: 10.7759/cureus.17564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose Surgical repair of the Achilles tendon is a common procedure in cases of acute rupture. Open Achilles tendon surgery with a traditional extensile approach is most often performed in the prone position, but this can lead to numerous complications. The mini-open approach for repair in the supine position may avoid the risks of the prone position. The purpose of this study is to compare perioperative outcomes and differences in cost between patients undergoing acute Achilles rupture repair with mini-open approach, incision of approximately 3 cm, in the supine position versus traditional approach in the prone position. Methods Patients who underwent surgical repair of acute Achilles rupture at a single institution were retrospectively identified using Current Procedural Terminology (CPT) code 27650. Complication rates and the total cost charged to the insurance companies of both the supine and prone groups were calculated. Results A total of 80 patients were included for analysis, 26 supine and 54 prone. The difference in average total time in the operating room was statistically significant. The prone position took approximately 15% more time (118.7 minutes) compared to the supine position (100 minutes) (p = 0.001). While not statistically significant, the total cost for the supine group ($19,889) was less than the for the prone group ($21,722) (p = 0.153) Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and deep vein thrombosis (DVT) rate were also similar between the two groups. No patient in either group experienced re-rupture of the Achilles tendon within the first year of primary repair. Conclusion The mini-open approach in the supine position may be advantageous in the repair of acute Achilles rupture in that it reduces total time in the operating room and total cost while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.
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Affiliation(s)
- Haley McKissack
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Ryan McLynn
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Charles Pitts
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Bradley Alexander
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - James Jones
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Nicholas A Andrews
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Zachary L Littlefield
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Ashish Shah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
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Hyer CF, Berlet G, Philbin T, Bull P, Brandão R, Prissel M, Malay DS. Does Functional Neuromuscular Electrical Stimulation (NMES) Influence Calf Atrophy Following Achilles Tendon Surgery? Prospective Double-Blind Randomized Controlled Trial on the Use of Immediate Postoperative Electrical Muscle Stimulation to Preserve Muscle Function and Volume. J Foot Ankle Surg 2021; 60:683-688. [PMID: 33736944 DOI: 10.1053/j.jfas.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 02/03/2023]
Abstract
Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m2 (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.
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Affiliation(s)
| | - Gregory Berlet
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Terry Philbin
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Patrick Bull
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Roberto Brandão
- Fellow Foot and Ankle Surgery, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Mark Prissel
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - D Scot Malay
- Director of Podiatric Research and Staff Surgeon, Penn Presbyterian Medical Center, Philadelphia, PA
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Naldo J, Agnew P, Brucato M, Dayton P, Shane A. ACFAS Clinical Consensus Statement: Acute Achilles Tendon Pathology. J Foot Ankle Surg 2021; 60:93-101. [PMID: 33199168 DOI: 10.1053/j.jfas.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/29/2020] [Indexed: 02/03/2023]
Abstract
Injuries to the Achilles tendon are a challenge to the foot and ankle surgeon. In recent years, research has led to a relative change in the way that many surgeons view acute Achilles tendon rupture. In an effort to fully evaluate these trends, as well as to evaluate all aspects of care for acute Achilles tendon rupture, the American College of Foot and Ankle Surgeons convened a panel of experts to create a clinical consensus statement to address selected aspects of care of the acute Achilles tendon injury.
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Affiliation(s)
- Jason Naldo
- Chairperson, ACFAS Acute Achilles Tendon Pathology Clinical Consensus Statement, Chicago, IL; Assistant Professor, Department of Orthopaedics, Virginia Tech Carilion School of Medicine, Roanoke, VA; Foot and Ankle Surgeon, Institute for Orthopaedics and Neurosciences, Carilion Clinic, Roanoke, VA.
| | - Patrick Agnew
- Director of Podiatric Medical and Surgical Education, Associate Professor, Eastern Virginia Medical School, Norfolk, VA
| | | | - Paul Dayton
- Private Practice, Foot & Ankle Center of Iowa, Ankeny, IA
| | - Amber Shane
- Chair, Department of Podiatric Surgery, Advent Health System, Orlando, FL; Faculty, Advent Health East Orlando Podiatric Surgical Residency, Orlando, FL
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Abstract
Postoperative complications can be burdensome on both the patient and the surgeon. Attention in literature is often directed toward different forms of treatment and successful outcomes in surgery. The incentive of this article is to bring insight toward postoperative complications in rearfoot surgery, more specifically, the repair of the Achilles tendon with suture tape and suture anchors. This article directs attention to the recent reports on hypersensitivity reactions seen with the use of suture tape and nonabsorbable suture anchors and may encourage physicians to make patients aware of this potential complication when using these materials.
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11
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Carpenter D, Dederer K, Weinhold P, Tennant JN. Clinical Outcomes and Cadaveric Biomechanical Analysis of Endoscopic Percutaneous Achilles Tendon Rupture Repair With Absorbable Suture. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420965967. [PMID: 35097413 PMCID: PMC8564947 DOI: 10.1177/2473011420965967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Percutaneous repair of acute Achilles tendon rupture (ATR) continues to gain in popularity. The primary aim of the study was to review the outcomes of a patient cohort undergoing a novel technique of endoscopic percutaneous Achilles tendon repair with absorbable suture. A secondary purpose of this study was to evaluate the basic biomechanical properties of the technique. Methods: A cohort of 30 patients who underwent percutaneous ATR repair was retrospectively analyzed with Achilles Tendon Rupture Scores (ATRS), complications, and additional outcome measures. For a biomechanical analysis portion of the study, 12 cadaveric specimens were paired and randomized to either novel percutaneous repair or open Kessler repair with absorbable suture. These specimens were subjected to 2 phases of cyclical testing (100 cycles 10-43 N followed by 200 cycles 10-86 N) and ultimate strength testing. Results: In the clinical portion of the study we report excellent patient reported outcomes (mean ATRS 94.1), high level of return to sport, and high patient satisfaction. One partial re-rupture was reported but with no major wound or neurologic complications. In the biomechanical portion of the study we found no significant difference in tendon gapping between percutaneous and open repairs in phase 1 of testing. In phase 2, increased gapping occurred between percutaneous (17.8 mm [range 10.7-24.1, SD 6.4]) and open repairs (10.8 mm [range 7.6-14.9, SD 2.7, P = .037]). The ultimate load at failure was not statistically different between the 2 repairs. Conclusions: A percutaneous ATR repair technique using endoscopic assistance and absorbable suture demonstrated low complications and good outcomes in a cohort of patients, with high satisfaction, and excellent functional outcomes including high rates of return to sport. Cadaveric biomechanical testing demonstrated excellent survival during testing and minimal increase in gapping compared with open repair technique, representing sufficient strength to withstand forces seen in early rehabilitation. A percutaneous Achilles tendon repair technique with absorbable suture may minimize risks associated with operative repair while still maintaining the benefit of operative repair. Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
| | | | - Paul Weinhold
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Joshua N. Tennant
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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12
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Bai L, Guan S, You T, Zhang W, Chen P. Comparison of Gastrocnemius Turn Flap and Hamstring Graft for the Treatment of Kuwada Type 3 Chronic Ruptures of the Achilles Tendon: A Retrospective Study. Orthop J Sports Med 2019; 7:2325967119887673. [PMID: 31840032 PMCID: PMC6900629 DOI: 10.1177/2325967119887673] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Chronic Achilles tendon rupture is challenging to repair, and many procedures
have been suggested to fill the gap that separates the distal and proximal
ends of the ruptured tendon. Purpose: To compare clinical outcomes between the free hamstring graft (HG) and
gastrocnemius turn flap (GTF) procedures in the treatment of chronic
Achilles tendon rupture. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective study included 26 patients (25 males, 1 female; mean age,
36.7 years; range, 22-53 years) with Kuwada type 3 chronic rupture of the
Achilles tendon. A total of 11 patients underwent GTF surgery, whereas 15
patients underwent HG surgery. Follow-up assessments were conducted at 3, 6,
and 12 months postoperatively. Results: The complication rate was significantly higher in the GTF group compared with
the HG group (27.2% vs 6.6%, respectively; χ2 = 12.462;
P = .001). At the 3-month follow-up, the degree of
ankle dorsiflexion was significantly higher in the HG group than in the GTF
group (t = 3.144; P = .004). At 6-month
and 1-year follow-up, no significant differences in ankle function were seen
between the 2 groups. Conclusion: Hamstring tendon graft is associated with better early recovery of
dorsiflexion compared with GTF. The long-term clinical outcomes of these 2
procedures are similar.
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Affiliation(s)
- Lu Bai
- Department of Sports Medicine, Peking University Shenzhen Hoapital, Shenzhen, Guangdong, China
| | - Siyao Guan
- Department of Sports Medicine, Peking University Shenzhen Hoapital, Shenzhen, Guangdong, China
| | - Tian You
- Department of Sports Medicine, Peking University Shenzhen Hoapital, Shenzhen, Guangdong, China
| | - Wentao Zhang
- Department of Sports Medicine, Peking University Shenzhen Hoapital, Shenzhen, Guangdong, China
| | - Peng Chen
- Department of Sports Medicine, Peking University Shenzhen Hoapital, Shenzhen, Guangdong, China
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Xia Z, Yew KSA, Zhang TK, Rikhraj IS. Lateral versus central tendon-splitting approach to insertional Achilles tendinopathy: a retrospective study. Singapore Med J 2019; 60:626-630. [PMID: 31044256 DOI: 10.11622/smedj.2019038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION This study aimed to compare operative outcomes between the lateral approach (LA) and the central approach (CA) to insertional Achilles tendinopathy (IAT). METHODS We retrospectively reviewed patients who underwent surgical treatment for IAT using the LA or CA. Patients' demographic data, postoperative complications and satisfaction rate were reviewed. Clinical outcomes were prospectively assessed preoperatively, at three months postoperatively and at the last visit, including patients' visual analogue scale (VAS) scores for pain, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores and 36-item Short Form Health Survey (SF-36) scores. RESULTS There were 39 patients in the LA group and 32 in the CA group. In each group, average VAS and AOFAS Scale scores improved significantly. SF-36 scores improved in most parameters. No significant difference in baseline score; average AOFAS Scale score at each visit; and mean VAS score preoperatively and at last visit; satisfaction rate; and overall complication rate were observed between the groups. The mean VAS score in the LA group at postoperative three months was significantly lower than that in the CA group (2.7 ± 2.5 vs. 4.4 ± 3.0; p = 0.016). There were significantly more cases of delayed wound healing in the LA group than in the CA group (2.6% vs. 15.6%; p = 0.049). CONCLUSION Both approaches had comparable outcomes for IAT in terms of functional improvement, pain relief, overall enhancement of patients' health condition and overall postoperative complication rate. The LA provided better short-term pain relief and reduced delayed wound healing compared with the CA.
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Affiliation(s)
- Zhan Xia
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Khye Soon Andy Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Ting Karen Zhang
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
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Hippensteel KJ, Johnson J, McCormick J, Klein S. A Comparison of Wound Complications With Surgical Treatment of Achilles Tendon Conditions Using 2 Surgical Approaches. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011418814004. [PMID: 35097313 PMCID: PMC8696824 DOI: 10.1177/2473011418814004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Wound complications are a concern with the open treatment of Achilles tendon conditions. The location of the incision may impact the risk of wound complications because of its relationship to the blood supply to the skin. There is no consensus as to the safest incision location. The purpose of this study was to evaluate and compare the rates of sural nerve injury and wound complications including superficial or deep infections and wound dehiscence between posterior midline and posteromedial surgical incision locations. Methods: 125 patients with Achilles tendon rupture or Achilles tendinopathy were treated with open surgery through a longitudinal posterior midline or posteromedial incision. An L-shaped incision was used in the posteromedial group for cases of insertional repair. Postoperative complications including sural nerve injuries, superficial wound complications, superficial infections, deep wound infections, return to the operating room, and need for soft tissue coverage were recorded and rates were compared between the groups. Results: No significant differences were detected between the posteromedial and posterior incision groups in rates of sural nerve injuries, superficial infection, or deep wound infection. The posterior incision group had significantly fewer wound complications. The wound complications in the posteromedial group primarily occurred when an L-shaped incision was used for insertional repair. No patients in either group required debridement or soft tissue/flap coverage. Conclusion: The posterior incision location had significantly fewer wound complications. The use of an L-shaped incision was likely responsible for the wound complications in this group rather than the location of the incision. The use of a medial incision was not found to decrease the rate of sural nerve injury. Level of Evidence: Level III.
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Affiliation(s)
- K. J. Hippensteel
- Department of Orthopedic Surgery, Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
| | - Jeffrey Johnson
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Jeremy McCormick
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sandra Klein
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, MO, USA
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Xia Z, Yew AKS, Zhang TK, Su HCD, Ng YCS, Rikhraj IS. Surgical Correction of Haglund's Triad Using a Central Tendon-Splitting Approach: A Retrospective Outcomes Study. J Foot Ankle Surg 2018; 56:1132-1138. [PMID: 28807379 DOI: 10.1053/j.jfas.2017.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Indexed: 02/03/2023]
Abstract
We evaluated the surgical outcomes of Haglund's triad using a central tendon-splitting approach, with Achilles tendon partial detachment and debridement, excision of the retrocalcaneal bursa, resection of Haglund's prominence, and reattachment of the Achilles tendon. The medical records of 22 patients (22 heels) who had undergone surgical correction of Haglund's triad from January 2010 to December 2015 were reviewed retrospectively. The visual analog scale pain score, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical and mental component scores were prospectively collected preoperatively, 6 months postoperatively, and at the last visit. The scores of a subjective question involving satisfaction were prospectively collected at the last visit. Possible risk factors were also evaluated. We reviewed the data from 12 females and 10 males, with the mean age of 59.2 ± 7.3 years and a mean follow-up duration of 15.1 ± 4.6 months. Significant improvement was found in the mean visual analog scale pain score, average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical component scale score. The overall satisfaction rate was 77.3% (17 of 22). Postoperative complications included 2 cases of delayed wound healing and 1 case of sensation loss over the heel wound. No Achilles tendon rupture or wound infection developed. Gender and body mass index did not affect the surgical outcomes. The surgical technique we used for Haglund's triad provided effective pain relief, function improvement, and overall enhancement of patients' health condition. More research is required to further evaluate the outcomes of our surgical approach to treat Haglund's triad and the possible risk factors.
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Affiliation(s)
- Zhan Xia
- Orthopaedic Resident, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
| | - Andy Khye Soon Yew
- Research Scientist, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Ting Karen Zhang
- Senior Executive, Orthopaedic Diagnostic Center, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Hsien Ching David Su
- Consultant, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Yung Chuan Sean Ng
- Consultant, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Inderjeet Singh Rikhraj
- Associate Professor and Senior Consultant, Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Abstract
BACKGROUND Open Achilles tendon surgery with the patient in the supine position potentially avoids the complications of the prone position, but the safety and viability of the supine position for this procedure are not known. The aim of this study was to test the hypothesis that supine positioning for open repair of acute Achilles tendon ruptures would be safe, with low wound and neurologic complication rates. METHODS Supine position safety in acute Achilles tendon repair was investigated. Consecutive cases of supine Achilles tendon surgical repair performed by one surgeon from 2010 to 2015 were retrospectively reviewed. Patients were included if they were surgically treated with primary repair in the supine position within 15 days of injury and did not undergo concomitant surgery. A paramedian incision 1 cm medial to the Achilles sheath was used. Initial chart review identified 161 patients who underwent any type of Achilles tendon surgery in the supine position, of whom 45 patients met the inclusion criteria. This group included 39 men and 6 women with an average age of 41 years (range, 20-66 years). Median length of follow-up was 116 days (range, 25-1,589 days). Average body mass index was 29 kg/m2 (range, 23-36 kg/m2). RESULTS There were no infections, sural nerve injuries, or reruptures. CONCLUSIONS The supine position was safe for primary open Achilles tendon repair, with no wound or neurologic complications. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- John J Marcel
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Katherine Sage
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Abstract
Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.
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Marican MM, Fook-Chong SMC, Rikhraj IS. Incidence of postoperative wound infections after open tendo Achilles repairs. Singapore Med J 2016; 56:549-54. [PMID: 26512146 DOI: 10.11622/smedj.2015150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Tendo Achilles (TA), which is the confluence of the gastrocnemius and soleus muscles, is one of the most commonly injured tendons. The surgical repair of TA ruptures is associated with a significant risk of infection. This study examined several factors (i.e. gender, age, body mass index, history of diabetes mellitus, steroid use, acute or chronic TA injuries, type of surgical incision and type of sutures used) that may be associated with postoperative wound infection after open TA repair. METHODS This was a retrospective study involving 60 patients who underwent open TA repair over an 18-month period. Patients who had prior TA surgery or open TA injuries, or who needed soft tissues flaps were excluded. RESULTS Among the patients, 7 (11.7%) developed superficial wound infections that were successfully treated with oral antibiotics, while 3 (5.0%) developed deep wound infections that required at least one debridement procedure. No significant association was found between the risk of postoperative wound infection and gender, age, the presence of diabetes mellitus, acute or chronic ruptures, site of surgical incision and type of deep or superficial sutures used. CONCLUSION While diabetes mellitus and age did not appear to be associated with postoperative wound infections after open TA repair, obese patients were found to be two times more likely to develop a wound infection than normal-weight patients. The incidence of superficial wound infections in this study was similar to previously published results (11.7% vs. 8.2%-14.6%), but the incidence of deep infections was higher (5% vs. 1%-2%).
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Affiliation(s)
- Mohd Mizan Marican
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Tansarli GS, Vardakas KZ, Stratoulias C, Peppas G, Kapaskelis A, Falagas ME. Vacuum-assisted closure versus closure without vacuum assistance for preventing surgical site infections and infections of chronic wounds: a meta-analysis of randomized controlled trials. Surg Infect (Larchmt) 2014; 15:363-7. [PMID: 24810943 DOI: 10.1089/sur.2013.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES We sought to examine whether vacuum-assisted closure (VAC) is associated with fewer surgical site infections (SSIs) or infections of chronic wounds than other management procedures for surgical wounds. METHODS The PubMed and Scopus databases were searched systematically. Randomized controlled trials (RCTs) comparing the development of SSIs or infections of chronic wounds between patients treated with VAC for acute or chronic wounds and those whose wounds were treated without VAC were considered eligible for inclusion in the study. RESULTS Eight RCTs met the inclusion criteria for the study. Four of the studies included chronic or diabetic lower extremity wounds and four included fractures. In three of four studies reporting on fractures, the wounds were not closed post-operatively, whereas in one study primary closure of the wound was performed. With regard to wounds left open after the stabilization of fractures, patients whose wounds were treated with VAC developed fewer SSIs than those whose wounds were treated without VAC ([367 patients (196 with VAC; 171 without VAC) relative risk [RR], 0.47; 95% CI 0.28-0.81]). On the contrary, no difference in the development of SSIs occurred among patients with chronic or diabetic lower-extremity wounds treated with VAC and those whose wounds were treated without VAC ([638 patients (320 with VAC; 318 without VAC) RR 1.67; 95% CI: 0.71-3.94]). CONCLUSION The available evidence suggests that the development of infections in wounds treated with VAC depends on the type of wound being treated.
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Greenhagen RM, Shinabarger AB, Pearson KT, Burns PR. Intermediate and long-term outcomes of the suture bridge technique for the management of insertional achilles tendinopathy. Foot Ankle Spec 2013; 6:185-90. [PMID: 23349381 DOI: 10.1177/1938640012473150] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Insertional Achilles tendinopathy is a problem frequently encountered by the foot and ankle surgeon. Conservative care yields mixed results, and this condition is often treated surgically. Our hypothesis is that the suture bridge technique through a central posterior incision allows adequate visualization for thorough debridement and exostectomy and provides a stable tendon-to-bone interface for healing. MATERIAL AND METHODS The medical records of 35 patients who underwent surgical treatment for insertional Achilles tendinopathy with the suture bridge technique, by a single surgeon, between 2006 and 2012 were retrospectively reviewed. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot instruments as well as a subjective questionnaire were utilized. RESULTS In all, 30 individuals who met the inclusion criteria for the treatment of insertional Achilles tendinopathy were evaluated at a mean follow-up of 28.93 ± 16.99 months. We included 10 men and 20 women, with a mean age of 49.1 ± 9.2 years. The mean preoperative AOFAS score was 56.6 ± 14.0. The average postoperative AOFAS score significantly increased to 91.7 ± 10.4 (P < .0001). One participant required revisional surgery, consisting of a flexor hallucis longus transfer performed by another physician. There were no wound complications or infections. Overall, there was a 97% (28/29) satisfaction rate. CONCLUSION The central incision with complete detachment of the Achilles tendon and reattachment with the suture bridge technique for the treatment of insertional Achilles tendinopathy provides an effective treatment with good to excellent clinical outcomes in 97% of patients, with a mean follow-up of 29 months.
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