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Wei S, Li Q, Wu H, Kong C, Xu F, Cai X. All-inside endoscopic semiautomatic running locked stitch technique shows favourable outcomes for acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2024; 32:1615-1621. [PMID: 38578228 DOI: 10.1002/ksa.12177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 04/06/2024]
Abstract
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.
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Affiliation(s)
- Shijun Wei
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Qing Li
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
| | - Helin Wu
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Changwang Kong
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
| | - Feng Xu
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Xianhua Cai
- Department of Orthopaedics, South China Hospital of Shenzhen University, Shenzhen, China
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Murphy CP, Safgren TJ, Piatt ET, Chong ACM, Piatt BE. Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair. J Foot Ankle Surg 2022; 62:45-49. [PMID: 35459614 DOI: 10.1053/j.jfas.2022.03.010] [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: 01/04/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/03/2023]
Abstract
Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.
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Affiliation(s)
- Colin P Murphy
- Department of Graduate Medical Education, Sanford Health, Fargo, ND; University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND; Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
| | - Tyler J Safgren
- University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND; Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
| | - Eric T Piatt
- Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
| | - Alexander C M Chong
- Department of Graduate Medical Education, Sanford Health, Fargo, ND; University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND.
| | - Bruce E Piatt
- Department of Graduate Medical Education, Sanford Health, Fargo, ND; University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND; Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
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Caolo KC, Eble SK, Rider C, Elliott AJ, Demetracopoulos CA, Deland JT, Drakos MC, Ellis SJ. Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211060063. [PMID: 35097483 PMCID: PMC8646203 DOI: 10.1177/24730114211060063] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques. METHODS A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution's registry. Demographics and complications were recorded. RESULTS PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection). CONCLUSION Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Kristin C. Caolo
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Stephanie K. Eble
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Carson Rider
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Andrew J. Elliott
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Jonathan T. Deland
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mark C. Drakos
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Scott J. Ellis
- Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
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Savić L, Augustyniak EM, Kastensson A, Snelling S, Abhari RE, Baldwin M, Price A, Jackson W, Carr A, Mouthuy PA. Early development of a polycaprolactone electrospun augment for anterior cruciate ligament reconstruction. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 129:112414. [PMID: 34579923 DOI: 10.1016/j.msec.2021.112414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
Despite the clinical success of Anterior Cruciate Ligament reconstruction (ACLR) in some patients, unsatisfactory clinical outcomes secondary to graft failure are seen, indicating the need to develop new regeneration strategies. The use of degradable and bioactive textiles has the potential to improve the biological repair of soft tissue. Electrospun (ES) filaments are particularly promising as they have the ability to mimic the structure of natural tissues and influence endogenous cell behaviour. In this study, we produced continuous polycaprolactone (PCL) ES filaments using a previously described electrospinning collection method. These filaments were stretched, twisted, and assembled into woven structures. The morphological, tensile, and biological properties of the woven fabric were then assessed. Scanning electron microscopy (SEM) images highlighted the aligned and ACL-like microfibre structure found in the stretched filaments. The tensile properties indicated that the ES fabric reached suitable strengths for a use as an ACLR augmentation device. Human ACL-derived cell cultured on the fabric showed approximately a 3-fold increase in cell number over 2 weeks and this was equivalent to a collagen coated synthetic suture commonly used in ACLR. Cells generally adopted a more elongated cell morphology on the ES fabric compared to the control suture, aligning themselves in the direction of the microfibres. A NRU assay confirmed that the ES fabric was non-cytotoxic according to regulatory standards. Overall, this study supports the development of ES textiles as augmentation devices for ACLR.
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Affiliation(s)
- Luka Savić
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Edyta M Augustyniak
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Adele Kastensson
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Snelling
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roxanna E Abhari
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andrew Price
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - William Jackson
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andrew Carr
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Pierre-Alexis Mouthuy
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
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Hartono F, Besinga KE, Tjie H, Marpaung D, Ananditya T, Gabriel H R N. Considerations in spontaneous quadriceps tendon rupture repair in end-stage renal disease patients: A case report. Int J Surg Case Rep 2021; 86:106298. [PMID: 34418804 PMCID: PMC8384894 DOI: 10.1016/j.ijscr.2021.106298] [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] [Received: 06/19/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Spontaneous quadriceps tendon rupture (SQTR) is a rare injury to the knee extensor mechanism that is usually associated with systemic diseases such as end stage renal diseases (ESRD) and it is more prevalent in the elderly. Due to the underlying pathology, quadriceps tendon rupture warrants special considerations and management in its repair. CASE REPORT We present two cases of quadriceps tendon rupture in end-stage renal disease (ESRD) patients. The first case; a 57 years old female who had bilateral SQTR and is undergoing hemodialysis. The second patient, a 26 years old male had unilateral quadriceps tendon rupture caused by minimal trauma. The first patient had a trans-osseous repair by direct suturing the quadriceps tendon stump to the proximal pole patella. The second patient was repaired with a modified Bunnel suture and anchor placement on the proximal pole patella. The first case had a re-rupture of the right quadriceps tendon and the second case has recovered with improved outcomes. DISCUSSION Spontaneous quadriceps tendon rupture is usually underlined by degenerative changes of the tendons. Special care is needed to address the pathologic tendon underlying SQTR. The current surgical literature still lacks the statistical data that shows which surgical approach is most optimal for SQTR in ESRD patients. CONCLUSION SQTR rupture is generally an injury of brittle tendons caused by underlying diseases. A multidisciplinary and comprehensive approach including a proper surgical approach and postoperative managements are crucial for good functional outcomes of the extensor mechanism.
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Affiliation(s)
- Franky Hartono
- Department of Orthopaedics and Traumatology, Pantai Indah Kapuk Hospital, Jakarta, Indonesia; Department of Orthopaedics and Traumatology, Siloam Hospitals Kebon Jeruk, Jakarta, Indonesia
| | - Karina E Besinga
- Department of Orthopaedics and Traumatology, Siloam Hospitals Kebon Jeruk, Jakarta, Indonesia
| | - Hendra Tjie
- Department of Internal Medicine, Pantai Indah Kapuk Hospital, Jakarta, Indonesia
| | - Daniel Marpaung
- Department of Orthopaedics and Traumatology, Pantai Indah Kapuk Hospital, Jakarta, Indonesia; Department of Orthopaedics and Traumatology, Siloam Hospitals Kebon Jeruk, Jakarta, Indonesia
| | - Tessi Ananditya
- Department of Orthopaedics and Traumatology, Siloam Hospitals Kebon Jeruk, Jakarta, Indonesia
| | - Nicholas Gabriel H R
- Department of Orthopaedics and Traumatology, Siloam Hospitals Kebon Jeruk, Jakarta, Indonesia.
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Diniz P, Pacheco J, Fernandes RM, Pereira H, Castelo Ferreira F, Kerkhoffs GMMJ. Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies. Knee Surg Sports Traumatol Arthrosc 2021; 31:1644-1657. [PMID: 34089335 DOI: 10.1007/s00167-021-06613-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Current treatment recommendations emphasize early loading, with preservation of tendon length and physiologic tension. The objective of this systematic review and network meta-analysis was to compare failure load and elongation after cyclic loading of Achilles tendon repair techniques at time-zero. METHODS The databases PubMed, CENTRAL and Web of Science were searched for all published in-vitro studies comparing Achilles tendon repair techniques, or augmentation with autografts/biomaterials, and reports of failure load or elongation after cyclic loading. Only studies using human cadaveric Achilles tendons and matched pairs, or randomized specimen allocation, were selected for quantitative synthesis. A network meta-analysis per primary outcome was performed. Results were summarized as P score rankings and their validity was assessed using statistical methods. RESULTS Sixteen studies, comprising 367 tendon repairs, were included. The following repair techniques were used (n = number of studies): Krackow (n = 8), Achillon (n = 4), double Krackow (n = 3), Bunnell (n = 3), Percutaneous Achilles Repair System (n = 3), Percutaneous Achilles Repair System Midsubstance (n = 2), Kessler (n = 3), double Kessler (n = 1), modified triple Kessler (n = 1), triple bundle (n = 1), a multifilament stainless steel cable-crimp technique (n = 1) and a double loop knot stitch (n = 1). Five studies assessed augmentation with autografts/biomaterials. Regarding the failure load, biomaterial augmented Krackow repairs occupied the first four positions in the ranking, followed by the multifilament stainless steel cable-crimp and Percutaneous Achilles Repair System Midsubstance techniques. Concerning elongation after cyclic loading, the triple Kessler was ranked first, followed by the Achillon and Percutaneous Achilles Repair System Midsubstance techniques. A negligible correlation between ranks was found (rs = 0.11; p = 0.75n.s.), meaning that a higher repair tensile strength is not necessarily related to improved performance in regard to avoidance of elongation. CONCLUSION In the failure load network meta-analysis, biomaterial augmented Krackow repairs ranked highest, but noticeable statistical heterogeneity was found. Regarding elongation with cyclic loading, the modified triple Kessler stitch showed the highest probability of ranking first. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Pedro Diniz
- Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela 501, 2775-028, Parede, Portugal.
- Department of Bioengineering, iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal.
- , Fisiogaspar, Lisboa, Portugal.
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal.
| | - Jácome Pacheco
- Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela 501, 2775-028, Parede, Portugal
| | - Ricardo M Fernandes
- Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisboa, Portugal
| | - Hélder Pereira
- Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal
- Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia, Madrid, Spain
- University of Minho ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Frederico Castelo Ferreira
- Department of Bioengineering, iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
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Akoh CC, Fletcher A, Sharma A, Parekh SG. Clinical Outcomes and Complications Following Limited Open Achilles Repair Without an Instrumented Guide. Foot Ankle Int 2021; 42:294-304. [PMID: 33148032 DOI: 10.1177/1071100720962493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides. METHODS A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses. RESULTS The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort. CONCLUSION Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | | | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Miller TL, Welder E. Achilles Tendon Repair With Modified Giftbox Technique Using Nonabsorbable Suture Loops. VIDEO JOURNAL OF SPORTS MEDICINE 2021. [DOI: 10.1177/2635025421992782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Achilles tendon ruptures occur most commonly in male individuals aged between 30 and 60 years. Indications: Surgical options for treatment of acute midsubstance Achilles tendon ruptures in the athletically active population include open, mini-open, and percutaneous techniques. Surgical Technique: The giftbox suture configuration has been popularized by multiple authors. Here, a modified giftbox technique for Achilles tendon repair is shown in detail and uses nonabsorbable suture loops, a novel method for primarily repairing complete Achilles tendon ruptures. Results: This mini-open technique has demonstrated, at a minimum of 1-year follow-up, outcomes that are comparable with previously reported Achilles tendon repair procedures with no re-ruptures and low overall complication rates in the first 60 patients who have undergone this procedure. The mean time to release to unrestricted activity following repair by this technique is 24.3 weeks, which is earlier than most standard techniques. Conclusion: Achilles tendon repair using the modified gift box technique with nonabsorbable suture loops is a safe and reliable technique for repair of midsubstance tendon ruptures in athletically active patients. The mean time to release to unrestricted activity following repair by this technique is earlier than most standard techniques.
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Affiliation(s)
- Timothy L. Miller
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric Welder
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Tian J, Rui Y, Xu Y, Yang W, Xu T, Chen X, Zhang X. A biomechanical comparison of Achilles tendon suture repair techniques: Locking Block Modified Krackow, Kessler, and Percutaneous Achilles Repair System with the early rehabilitation program in vitro bovine model. Arch Orthop Trauma Surg 2020; 140:1775-1782. [PMID: 32712822 DOI: 10.1007/s00402-020-03535-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/15/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Krackow technique has the advantage of high strength, though it is not minimally invasive. The "Locking Block Modified Krackow" (LBMK) peri-tendon fixation technique was designed for minimally invasive surgery. This study aimed to compare the biomechanics of LBMK with Kessler and Percutaneous Achilles Repair System (PARS) techniques using a simulated early rehabilitation program. MATERIALS AND METHODS Thirty-fresh bovine Achilles tendon specimens were randomly assigned to the LBMK, Kessler, and PARS groups (n = 10). In LBMK group, the main suture configuration was the LBMK technique, and the transverse suture was used as the secondary suture configuration. The Kessler group employed three suture configurations, two sagittal, one coronal plane. In the PARS group, two transverse and one locking sutures were placed at either end of the tendon. Each repaired specimen underwent two cyclic loading protocols (20-100 N, 20-190 N), 500 cycles, followed by measurement of the gap between the tendon ends. All specimens underwent a load-to-failure test at a 25 mm/s stretching rate. RESULTS After the first loading cycle, the average gaps of the LBMK, Kessler and PARS groups were 0.76 ± 0.44 mm, 1.80 ± 0.82 mm, and 2.66 ± 1.04 mm, respectively. The LBMK group had a significantly reduced gap than the other groups (p < 0.01). The LBMK group gaps were all within 2 mm. The Kessler and PARS groups had six, and two specimens within 2 mm, respectively. After the second loading cycle, the average end gaps of the LBMK, Kessler, and PARS groups were 3.68 ± 1.08 mm, 5.70 ± 0.89 mm and 7.59 ± 1.26 mm, respectively. The LBMK group had a significantly reduced average gap than the other groups (p < 0.01). The maximum load-to-failure was highest 732.8 ± 138 N in the LBMK than the other groups (p < 0.01). CONCLUSION The biomechanical strength of the LBMK suture was significantly greater than Kessler and PARS. The reduced gap in the LBMK group suggests superior resistance to gap formation, which may occur during early postoperative rehabilitation.
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Affiliation(s)
- Jian Tian
- Department of Orthopedics, Soochow University Affiliated Wuxi Ninth People's Hospital, Wuxi, China.
| | - Yongjun Rui
- Department of Orthopedics, Soochow University Affiliated Wuxi Ninth People's Hospital, Wuxi, China
| | - Yajun Xu
- Department of Orthopedics, Soochow University Affiliated Wuxi Ninth People's Hospital, Wuxi, China
| | - Wengbo Yang
- Department of Orthopedics, Nanjing Medical University Affiliated Nanjing First Hospital, Nanjing, China
| | - Tonglong Xu
- Department of Orthopedics, Soochow University Affiliated Wuxi Ninth People's Hospital, Wuxi, China
| | - Xueming Chen
- Department of Orthopedics, Soochow University Affiliated Wuxi Ninth People's Hospital, Wuxi, China
| | - Xingfei Zhang
- Department of Orthopedics, Soochow University Affiliated Wuxi Ninth People's Hospital, Wuxi, China
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Čretnik A, Kosanović M, Košir R. Long-Term Results With the Use of Modified Percutaneous Repair of the Ruptured Achilles Tendon Under Local Anaesthesia (15-Year Analysis With 270 Cases). J Foot Ankle Surg 2019; 58:828-836. [PMID: 31474397 DOI: 10.1053/j.jfas.2018.11.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 02/03/2023]
Abstract
Controversy regarding the optimal treatment of fresh total Achilles tendon rupture remains. This article presents results with the use of modified percutaneous Achilles tendon repair under local anesthesia performed from January 1991 to December 2005 with a 2- to 10-year follow-up. There were 270 procedures in 247 male patients (92.51%) and 20 female patients (7.49%), mean ± SD age 38.7 ± 11.56 (range 20 to 83) years, in all consecutively treated patients within 7 days after acute total rupture; 3 patients sustained ruptures on both sides in different periods. Postoperative care consisted of wearing a cast or soft cast or functional immobilization for 6 weeks. The procedure was well tolerated in all patients. There were 3 (1.11%) complete and 5 (1.85%) partial repeat ruptures (8 [2.96%] altogether). Fourteen patients (5.18%) developed transient sural neuritis that spontaneously resolved in 2 to 10 months. One case (0.3%) of deep venous thrombosis was successfully treated. There were 25 (9.36%) major and minor complications altogether, with no cases of increased postoperative dorsiflexion, deep infection, or necrosis. Forty-four patients (16.48%) had a slightly decreased range of ankle motion, and 216 (80.89%) patients, including all high-caliber athletes, resumed all their previous activities. The mean American Orthopedic Foot and Ankle Society hindfoot-ankle score was 96.10 points. Long-term results of the analyzed modified method suggest a reasonable treatment option for acute total Achilles tendon ruptures, with a low number of complications and repeat rupture rate and return to preinjury activities comparable to those of open procedures.
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Affiliation(s)
- Andrej Čretnik
- Professor of Surgery, General and Trauma Surgeon, Department of Traumatology, University Clinical Centre Maribor, Maribor, Slovenia.
| | - Miloš Kosanović
- Orthopaedic and Trauma Surgeon, Department of Traumatology, General and Teaching Hospital Celje, Celje, Slovenia
| | - Roman Košir
- Assistant, General Surgeon, Department of Traumatology, University Clinical Centre Maribor, Maribor, Slovenia
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Frantz TL, Everhart JS, Jamieson M, Fisk E, Fredrickson S, Kanney J, Miller TL. Patient-Reported Outcomes of Achilles Tendon Repair Using the Modified Gift-Box Technique With Nonabsorbable Suture Loop: A Consecutive Case Series. J Foot Ankle Surg 2019; 58:696-701. [PMID: 31079985 DOI: 10.1053/j.jfas.2018.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Indexed: 02/03/2023]
Abstract
We sought to determine the early range of motion, complication rates, and 1-year patient-reported outcomes following Achilles tendon repair, using a modified gift-box suture loop technique. Sixty consecutive patients (49 males, mean age 36.2 ± 9.9 years) who underwent Achilles tendon repair with a modified gift-box suture loop technique performed by a single surgeon were prospectively enrolled. The range of motion at the final follow-up visit (mean 6 months) and the Achilles tendon rupture score (ATRS) and the complication rates at 1 year were obtained with 83% follow-up. The predictors of complications and ATRS were assessed. The mean operative time was 63.1 ± 10.8 minutes, which decreased throughout the case series (r = 0.46, p < .001). The mean plantarflexion at the final office evaluation was 31.7° ± 6.2°, dorsiflexion was 11.7° ± 6.3°, and total ankle arc of motion was 43.6° ± 9.7°; longer length of follow-up was associated with greater dorsiflexion (p = .008) and the total arc of motion (p = .008) but not with plantarflexion (p = .16). The overall rerupture rate was 1.7% (1 patient), wound complication rate was 1.7% (1 patient), and the overall complication rate was 6.7% (4 patients). No predictors of complications were identified. Complication rates did not differ between the first 30 (6.7%) cases and second 30 (6.7%) cases. The mean ATRS at 1 year was 81.8 ± 16.8 points. The rerupture and overall complication rates by 1 year were low. The range of motion, particularly dorsiflexion, improved through at least 6 months. Diabetic patients had lower 1-year ATRS than nondiabetic patients using this technique.
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Affiliation(s)
- Travis L Frantz
- Orthopaedic Resident, Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Joshua S Everhart
- Orthopaedic Resident, Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Marissa Jamieson
- Assistant Professor, Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Saul Fredrickson
- Orthopaedic Resident, Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jill Kanney
- Medical Student, Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy L Miller
- Associate Professor, Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, OH.
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Ateschrang A, Salewski C, Ahrend MD, Schreiner AJ, Hirschmann MT, Stöckle U, Ahmad SS. The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping. Knee Surg Sports Traumatol Arthrosc 2019; 27:971-977. [PMID: 29761212 DOI: 10.1007/s00167-018-4972-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/27/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE Most biomechanical investigations of tendon repairs were based on output measures from hydraulic loading machines, therefore, accounting for construct failure rather than true gapping within the rupture zone. It was hypothesized that the elastic capacity of a tendon-repair construct influences the force necessary to induce gapping. METHODS A tendon-repair model was created in 48 porcine lower hind limbs, which were allocated to three fixation techniques: (1) Krackow, (2) transosseous and (3) anchor fixation. Loading was performed based on a standardized phased load-to-failure protocol using a servohydraulic mechanical testing system MTS (Zwick Roell, Ulm, Germany). Rupture-zone dehiscence was measured with an external motion capture device. Factors influencing dehiscence formation was determined using a linear regression model and adjustment performed as necessary. A 3-mm gap was considered clinically relevant. Analysis of variance (ANOVA) was used for comparison between groups. RESULTS The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping of 3 mm (F3mm) [β = 0.6, confidence interval (CI) 0.4-1.0, p < 0.001]. Furthermore, the three methods of fixation did not differ significantly in terms of maximum force to failure (n.s) or F3mm (n.s). CONCLUSION The main finding of this study demonstrated that the higher the elastic capacity of a tendon-repair construct, the higher the force necessary to induce clinically relevant gapping. LEVEL OF EVIDENCE Controlled biomechanical study.
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Affiliation(s)
- Atesch Ateschrang
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Christoph Salewski
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Marc-Daniel Ahrend
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Anna Janine Schreiner
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Tübingen, Germany.
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Ulrich Stöckle
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Sufian S Ahmad
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital of Bern, Bern, Switzerland
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Editorial Commentary: Is Endoscopy Really Helpful During Repair of Acute Rupture of the Achilles Tendon? Arthroscopy 2018; 34:1270-1271. [PMID: 29622260 DOI: 10.1016/j.arthro.2017.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 02/02/2023]
Abstract
Endoscopically assisted Achilles tendon repair is an attractive minimally invasive approach to reduce the risk of sural nerve injury. However, I do not believe that endoscopy is necessary for all types of minimally invasive Achilles tendon repair. Endoscopy is only helpful to make suture passage through the proximal lateral portal safe. It cannot help to reduce the risk of sural nerve injury if the tendon is repaired with percutaneous locking sutures. Abandonment of the proximal lateral portal and development of "all-inside" endoscopic repair of the Achilles tendon with locking sutures should be the future goal.
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Sherman SL. Editorial Commentary: The Krackow Stitch: More Than 30 Years of Tendon Repair and Still Holding Strong. Arthroscopy 2018; 34:669-670. [PMID: 29502688 DOI: 10.1016/j.arthro.2017.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
Security at the suture-tendon interface is a critical component of soft tissue fixation. For more than 3 decades, the Krackow stitch has been considered the gold standard for soft tissue fixation. Modifications of the original configuration have withstood the test of time. Many have been evaluated in preclinical and clinical studies for multiple musculoskeletal applications. Most recently, double Krackow suture configurations have been shown to increase the ultimate failure load of the suture-tendon construct. I have learned this stitch and will add it to my soft tissue fixation arsenal.
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