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Diaz MA, Branch EA, Dunn JG, Brothers A, Jordan SE. Whip-Lock Stitch Is Biomechanically Superior to Whipstitch for Semitendinosus Tendons. Arthrosc Sports Med Rehabil 2024; 6:100853. [PMID: 38304466 PMCID: PMC10830526 DOI: 10.1016/j.asmr.2023.100853] [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] [Received: 07/31/2023] [Accepted: 11/18/2023] [Indexed: 02/03/2024] Open
Abstract
Purpose To assess the biomechanical performance of different stitching methods using a suturing device by comparing the elongation, stiffness, failure load, and time to stitch completion in cadaveric semitendinosus tendons (STs) and quadriceps tendons (QTs). Methods A total of 24 STs and 16 QTs were harvested from cadaveric knee specimens (N = 40). Samples were randomly divided into 2 groups: whipstitch (WS) and whip-lock (WL) stitch. Both tendon ends were clamped to a graft preparation stand, and a 2-part needle was used to place 5 stitches, each 0.5 cm apart. Stitching time was recorded. Samples were preconditioned and then underwent cyclic loading from 50 to 200 N at 1 Hz for 500 cycles, followed by load-to-failure testing at 20 mm/min. Stiffness (in newtons per millimeter), ultimate failure load (in newtons), peak-to-peak displacement (in millimeters), elongation (in millimeters), and failure displacement (in millimeters) were recorded. Results Completion of the WS was significantly faster than the WL stitch in the ST (P < .001) and QT (P = .004). For the ST, the WL stitch exhibited higher ultimate failure loads and construct stiffness than the WS. Regarding the QT, the WL stitch showed higher stiffness and displacement than the WS; however, the ultimate failure load was higher for the WS in the QT. The ultimate failure load in the QT was higher than that in the ST for both stitches. In the ST, only 25% of WSs and 100% of WL stitches failed due to suture breakage. In the QT, suture breakage led to the failure of 100% of both the WL stitches and WSs. Conclusions In the ST, the WL stitch resulted in improved biomechanical performance through higher ultimate load and fewer failures from tissue damage compared with the WS. In the QT, both the WS and the WL stitch showed similar biomechanical performance with ultimate failure loads above established clinical failure thresholds. Clinical Relevance Various types of ligament and tendon injuries require suturing to enable repair or reconstruction. The success of ligament or tendon surgery often relies on soft-tissue quality. It is important to investigate the biomechanical properties of stitching techniques that help preserve soft-tissue quality as a step to determining their clinical suitability.
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Affiliation(s)
- Miguel A. Diaz
- Foundation for Orthopaedic Research and Education, Tampa, Florida, U.S.A
| | - Eric A. Branch
- Tallahassee Orthopedic Clinic, Panama City, Florida, U.S.A
| | - Jacob G. Dunn
- St. Francis Orthopaedic Institute, Columbus, Georgia, U.S.A
| | - Anthony Brothers
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A
| | - Steve E. Jordan
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A
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2
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Samal S, Samal S, Thakre VM. The Significance of Proprioceptive Training in the Post-Operative Rehabilitation of Patients Undergoing Achilles Tendon Reconstruction. Cureus 2024; 16:e54431. [PMID: 38510861 PMCID: PMC10951674 DOI: 10.7759/cureus.54431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
In the human anatomy, the Achilles tendon (AT) is the strongest and largest tendon. Also, it ruptures the most often. Because it impairs the patient's ability to function adequately, a ruptured AT injury is a serious clinical issue. Reconstruction of the tendon through surgical intervention is the preferred approach to treatment in the case of tendon rupture. Establishing an effective post-operative rehabilitation regimen that mostly consists of functional physiotherapy measures is crucial in the management of AT rupture. In this report, we have presented the case of an AT reconstruction patient who complained of pain in the ankle region, reduced strength and range of the ankle joint, and loss of proprioception. The tailor-made physiotherapy protocol was incorporated, which included strengthening exercises, proprioceptive retraining, cryotherapy, and ambulatory training, which were found to be effective in facilitating early functional recovery.
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Affiliation(s)
- Snehal Samal
- Neuro Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Subrat Samal
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Vaishnavi M Thakre
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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3
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Adames MK, Santos APG, Daleffe MR, Krummenauer Formenton AB, Pinto O, de Mello Roesler CR. Biomechanical comparison of shoelace suture technique for repairing calcaneal tendon. Injury 2023; 54:111134. [PMID: 37890290 DOI: 10.1016/j.injury.2023.111134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The biomechanical assessment of tendon repair is essential for the evaluation of different tendon suturing techniques. The shoelace suture technique with absorbable Vicryl® is a modified technique of Achilles tendon repair that may have biomechanical advantages depending on the number of threads used and the direction of the suture. PURPOSE To evaluate the creep under constant pre-load, the stiffness, the maximum strength, and the failure mode for three different configurations of the shoelace suture in a bovine tendon biomechanical model. STUDY DESIGN Controlled Laboratory Study. METHODS 36 bovine Achilles tendon specimens were acquired and divided into three test groups of 12 Achilles tendons each. A model of the calcaneal tendon rupture was created through a transverse cut with a scalpel, performed 5 centimeters proximal to the calcaneal bone insertion. Group 1 was repaired using the simple shoelace technique with just one suture. Group 2 was repaired using the shoelace technique with three sutures individually sutured from distal to proximal at the site of rupture. Group 3 was repaired using the shoelace technique with three sutures individually sutured from proximal to distal at the site of rupture. RESULTS System creep after constant pre-load was 5.9 ± 2.5 mm, 3.0 ± 0.4 mm and 2.9 ± 0.4 mm for groups 1, 2 and 3, respectively. The system's stiffness was 23.2 ± 2.8 N/mm, 30.3 ± 1.1 N/mm and 29.8 ± 2.3 N/mm for groups 1, 2 and 3, respectively. In the final load-to-failure test, the ultimate load force (ULF) was 158.2 ± 27.5 N, 346.5 ± 47.6 N and 358.1 ± 41.6 N for groups 1, 2 and 3, respectively. There was statistical significance in the comparative tests between groups 1-2 and 1-3 in terms of means of creep, system stiffness and maximum system strength. No statistically significant difference was found between groups 2 and 3 when analyzing creep, system stiffness and ULF. Suture breakage was the prevalent mode of failure for all tested groups. CONCLUSION The shoelace with three sutures significantly reduced creep in the preloading phase and increased the stiffness and ultimate load force. The biomechanical results demonstrate better overall mechanical performance of the technique than the simple shoelace technique. The better mechanical performance indicates that the shoelace with three sutures could result in early postoperative rehabilitation. CLINICAL RELEVANCE This study indicates that the shoelace suture technique with three sutures is biomechanically strong and stiff, being a possible therapeutic option to be used.
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Affiliation(s)
- Mário Kuhn Adames
- Homero de Miranda Gomes Regional Hospital, São José, and Adames Central Medic(CMA), Florianópolis, SC, Brazil.
| | - Arthur Paiva Grimaldi Santos
- Biomechanichal Engineering Laboratory, University Hospital, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Murilo Romancini Daleffe
- Homero de Miranda Gomes Regional Hospital, São José, and Adames Central Medic(CMA), Florianópolis, SC, Brazil
| | - Ana Bárbara Krummenauer Formenton
- Biomechanichal Engineering Laboratory, University Hospital, Federal University of Santa Catarina, Florianópolis, SC, Brazil; Federal University of Rio Grande doSul (Applied Mechanics Group), Brazil
| | - Otávio Pinto
- Biomechanichal Engineering Laboratory, University Hospital, Federal University of Santa Catarina, Florianópolis, SC, Brazil
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4
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Muscatelli S, Walley KC, Daly-Seiler CS, Greenstein JA, Sciascia A, Patterson DP, Freehill MT. Biomechanical Comparison of a Novel Multiplanar, Perpendicular Whipstitch With the Krackow Stitch and Standard Commercial Whipstitch. Orthop J Sports Med 2022; 10:23259671221107034. [PMID: 35982831 PMCID: PMC9380225 DOI: 10.1177/23259671221107034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Using alternating orthogonal suture throws with the looped whipstitch
technique may allow enhanced suture fixation. Hypothesis: It was hypothesized that this novel multiplanar, perpendicular looped
whipstitch (MP) technique would have improved biomechanical properties
compared with the standard looped whipstitch (WS) and Krackow stitch
(KS). Study Design: Controlled laboratory study. Methods: A total of 30 cadaveric tibialis anterior tendons were randomly assigned into
3 groups of 10. Tendons were secured to a custom clamp, and the other end
was sutured using 1 of 3 techniques: the KS, WS, or novel MP. The MP was
performed with alternating orthogonal throws starting right to left, then
front to back, left to right, and back to front. Each technique used 4
passes of No. 2 FiberWire spaced 5 mm apart and ending 10 mm from the tendon
end. Tendons were preloaded to 5 N, pretensioned to 50 N at 100 mm/min for 3
cycles, returned to 5 N for 1 minute, cycled from 5 to 100 N at 200 mm/min
for 100 cycles, and then loaded to failure at 20 mm/min. Elongation was
recorded after pretensioning and cycling and was measured both across the
suture-tendon interface and from the base of the suture-tendon interface to
markings on the suture limbs (construct elongation). One-way analyses of
variance were performed, with Bonferroni post hoc analysis when
appropriate. Results: There were no differences in cross-sectional area or stiffness among the 3
techniques. The ultimate load for WS (183.33 ± 57.44 N) was less compared
with both MP (270.76 ± 39.36 N) and KS (298.90 ± 25.94 N)
(P ≤ .001 for both). There was less construct
elongation for KS compared with WS and MP for total displacement, measured
from pretensioning to the end of cycling (P < .001). All
3 techniques saw a decrease in length (shortening) at the suture-tendon
interface during testing. There was more shortening at the suture-tendon
interface for WS compared with KS (P = .006). Conclusion: The KS appears superior, as it maximized strength while minimizing construct
elongation or graft shortening. The ultimate load of the MP technique was
greater than that of the standard technique but not significantly different
from that of the KS technique. Clinical Relevance: The KS is preferred. If using a WS, multiplanar, perpendicular passes should
be considered.
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Affiliation(s)
| | | | | | | | | | - David P Patterson
- University of Michigan Health System, Ann Arbor, Michigan, USA.,Ann Arbor VA Healthcare System, Ann Arbor, Michigan, USA
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5
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Carmont MR, Brorsson A, Barfod KW, Ginder L, Littlehales J, Karlsson J, Nilsson-Helander K. The reliability, reproducibility and utilization of the radiographic Achilles Tendon Loading Angle in the management of Achilles Tendon rupture. Foot Ankle Surg 2021; 27:760-766. [PMID: 33059973 DOI: 10.1016/j.fas.2020.09.013] [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: 07/20/2020] [Revised: 09/16/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND During management of Achilles tendon rupture, determination of tendon-end approximation, either clinically or by ultrasound is difficult, following brace application of during loading. The Radiographic Achilles Tendon Loading Angle (RadATLA) is proposed as a method of measuring ankle position whilst loading in a brace during the management of Achilles tendon rupture. This study aims to determine the reliability and reproducibility of the RadATLA. METHODS A loaded true lateral ankle radiograph including the fifth metatarsal head was taken when wearing a brace at the 6-week time point in 18 patients (19 ankles). following Achilles tendon repair or reconstruction. The RadATLA was compared with the Tibio-talar angle, other radiographic and clinical measures used to quantify foot and ankle position during the first 6 weeks of early rehabilitation in a resting position and during loading. RESULTS The intra-rater reliability of both angles was found to be good (>0.8). The RadATLA was found to have an excellent intra-rater reliability with Intra-class correlation of (ICC) 0.992-0.996 (95%CI 0.889-0.999), standard error of the measurement (SEM) 1.03-3.65 and Minimal Detectable Change (MDC) 2.86-10.12. The inter-rater reliability was good with ICC of 0.798-0.969 (95%CI-0.03 to 0.964), SEM 2.9-7.6, and MDC 8.1-20.9. The RadATLA loaded at 6 weeks in all patients was at mean (SD) (range) 41.9˚ (16.5), (18.5-75.9). There was a significant difference between the patients in the Repair group compared with patients in the Reconstruction group both in RadATLA loaded at 6 weeks: 35.6˚ (11.2), (18.5-56.5) versus 55.5˚ (19), (20-75.9), (p = 0.01). The amount loaded in all patients was at mean (SD) (range) 29.2Kg (17.7), (2-56) and the percentage Body Weight was 30.7% (19), (2.1-63.2). There were no differences between the groups neither in amount loaded nor in percentage Body weight (p = 0.614-0.651). CONCLUSIONS The RadATLA is a reliable and reproducible angle and can be used to determine the position of the ankle, when loaded in a brace during rehabilitation following Achilles tendon rupture.
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Affiliation(s)
- Michael R Carmont
- The Department of Trauma & Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden.
| | - Annelie Brorsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Laurence Ginder
- The Department of Radiology & Imaging, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom
| | - Julie Littlehales
- The Department of Trauma & Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom
| | - Jón Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden
| | - Katarina Nilsson-Helander
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden
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6
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Costa ML, Achten J, Wagland S, Marian IR, Maredza M, Schlüssel MM, Liew AS, Parsons NR, Dutton SJ, Kearney RS, Lamb SE, Ollivere B, Petrou S. Plaster cast versus functional bracing for Achilles tendon rupture: the UKSTAR RCT. Health Technol Assess 2021; 24:1-86. [PMID: 32068531 DOI: 10.3310/hta24080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Achilles tendon rupture affects > 11,000 people each year in the UK, leading to prolonged periods away from work, sports and social activities. Traditionally, the ruptured tendon is held still in a plaster cast for ≥ 8 weeks. Functional bracing is an alternative treatment that allows patients to mobilise earlier, but there is little evidence about how bracing affects patients' recovery. OBJECTIVES To measure the Achilles Tendon Rupture Score, quality of life, complications and resource use of patients receiving non-operative treatment for an Achilles tendon rupture treated with plaster cast compared with those treated with functional bracing. DESIGN This was a multicentre, randomised, pragmatic, two-group superiority trial. SETTING The setting was 39 NHS hospitals. PARTICIPANTS A total of 540 adult patients treated non-operatively for Achilles tendon rupture were randomised from July 2016 to May 2018. Exclusion criteria included presenting after 14 days, having had previous rupture and being unable to complete questionnaires. INTERVENTIONS A total of 266 participants had a plaster cast applied, with their toes initially pointing to the floor. The cast was changed over 8 weeks to bring the foot into a walking position. A total of 274 patients had a functional brace that facilitated immediate weight-bearing. The foot position was adjusted within the brace over the same 8-week period. MAIN OUTCOME MEASURES Achilles Tendon Rupture Score is patient reported and assesses symptoms and physical activity related to the Achilles tendon (score 0-100, with 100 being the best possible outcome). The secondary outcomes were quality of life, complications and resource use at 8 weeks and at 3, 6 and 9 months. RESULTS Participants had a mean age of 48.7 years, were predominantly male (79%) and had ruptured their tendon during sports (70%). Over 93% of participants completed follow-up. There was no statistically significant difference in Achilles Tendon Rupture Score at 9 months post injury (-1.38, 95% confidence interval -4.9 to 2.1). There was a statistically significant difference in Achilles Tendon Rupture Score at 8 weeks post injury in favour of the functional brace group (5.53, 95% confidence interval 2.0 to 9.1), but not at 3 or 6 months post injury. Quality of life showed the same pattern, with a statistically significant difference at 8 weeks post injury but not at later time points. Complication profiles were similar in both groups. Re-rupture of the tendon occurred 17 times in the plaster cast group and 13 times in the functional brace group. There was no difference in resource use. CONCLUSIONS This trial provides strong evidence that early weight-bearing in a functional brace provides similar outcomes to traditional plaster casting and is safe for patients receiving non-operative treatment of Achilles tendon rupture. The probability that functional bracing is cost-effective exceeds 95% for the base-case imputed analysis, assuming a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. On average, functional brace is associated with lower costs (-£103, 95% confidence interval -£290 to £84) and more quality-adjusted life-years (0.015, 95% confidence interval -0.0013 to 0.030) than plaster cast. LIMITATIONS Some patients declined to participate in the trial, but only a small proportion of these declined because they had a preference for one treatment or another. Overall, 58% of eligible patients agreed to participate, so the participants are broadly representative of the population under investigation. FUTURE WORK Although the UK Study of Tendo Achilles Rehabilitation provides guidance with regard to early management, rehabilitation following Achilles tendon rupture is prolonged and further research is required to define the optimal mode of rehabilitation after the initial cast/brace has been removed. TRIAL REGISTRATION Current Controlled Trials ISRCTN62639639. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Juul Achten
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan Wagland
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ioana R Marian
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mandy Maredza
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Maia Schlüssel
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anna S Liew
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nick R Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Susan J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Rebecca S Kearney
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
| | - Benjamin Ollivere
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, Queen's Medical Centre Nottingham, University of Nottingham, Nottingham, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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7
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Xu XY, Gao S, Lv Y, Zhou F, Jiao C, Fan JX, Zhu TJ. Duration of immobilisation after Achilles tendon rupture repair by open surgery: a retrospective cohort study. J Orthop Surg Res 2021; 16:196. [PMID: 33731160 PMCID: PMC7968267 DOI: 10.1186/s13018-021-02342-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/09/2021] [Indexed: 12/28/2022] Open
Abstract
Background The best treatment for acute Achilles tendon ruptures remains controversial. No cohort studies have compared different immobilisation durations after open surgery. This retrospective cohort study aimed to determine the optimal duration of immobilisation after this surgery. Methods A total of 266 patients with acute Achilles tendon rupture were divided into 4 groups (A, B, C, and D) according to immobilisation duration of 0, 2, 4, and 6 weeks, respectively. All patients underwent the same suture technique with a similar rehabilitation protocol and were examined clinically at 2, 4, 6, 8, 10, 12, 14, 16, 24, and 48 weeks, with a final follow-up at a mean of 22.3 months postoperatively. The primary outcome was the time of return to light sports activity (LSA). Secondary outcomes included range of motion (ROM) and single-legged heel rise height (SHRH). Data on operation time, complications, visual analogue pain scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Achilles tendon Total Rupture score (ATRS) were also collected. Demographic baseline data were analysed using one-way analysis of variance; outcome parameters were analysed using Kruskal-Wallis H test, and complications were analysed using Fisher’s exact test. Statistical significance was considered at P ≤ 0.05. Results VAS scores decreased significantly, reaching 0 in all groups after 12 weeks. The AOFAS and ATRS scores were significantly different between the groups from weeks 2 to 12 (P<0.001) and weeks 2 to 16 (P<0.001), respectively. All the mean scores showed better results in group B than in the other groups. In terms of recovery time of ROM, SHRH, and LSA, groups A and B were significantly faster than groups C and D (P<0.001). There were 13 (13/266, 4.9%) complications: 5 superficial infections, 3 deep venous thrombosis, and 5 trauma-related re-ruptures. On the last follow-up, all complications had recovered. There were no significant differences in complications between the groups. Conclusions Immobilisation for 2 weeks after this open surgery is the best choice for early rehabilitation and weight-bearing while minimising pain and other complications.
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Affiliation(s)
- Xiang Yu Xu
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Shan Gao
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Yang Lv
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China.
| | - Fang Zhou
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China.
| | - Chen Jiao
- Department of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Ji Xing Fan
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Teng Jiao Zhu
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
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8
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Kayani B, Singh S, Chang JS, Magan AA, Plastow R, Haddad FS. Outcomes of Surgical Repair Versus Primary Tenodesis for Proximal Rectus Femoris Avulsion Injuries in Professional Athletes. Am J Sports Med 2021; 49:121-129. [PMID: 33381991 DOI: 10.1177/0363546520970912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical repair of proximal rectus femoris avulsion injuries is associated with prolonged periods of rehabilitation and highly variable risk of injury recurrence. Surgical tenodesis of these injuries is often reserved for recurrent injuries or revision surgery. To our knowledge, the outcomes of proximal rectus femoris avulsion injuries treated with surgical repair versus primary tenodesis have not been previously reported. HYPOTHESIS Primary tenodesis of proximal rectus femoris avulsion injuries is associated with reduced risk of injury recurrence as compared with surgical repair. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This study included 25 patients (22 male and 3 female) who underwent surgical repair versus 30 patients (26 male and 4 female) who received primary tenodesis for proximal rectus femoris avulsion injuries. Predefined outcomes were recorded at regular intervals after surgery. Mean follow-up time was 27.9 months (range, 24.0-31.7 months) from date of surgery. RESULTS All patients returned to their preinjury levels of sporting activity. Primary tenodesis was associated with earlier return to preinjury level of sporting function as compared with surgical repair (mean ± SD, 12.4 ± 1.6 vs 15.8 ± 2.2 weeks; P < .001) and reduced risk of recurrence (0% vs 16%; P < .001). At 1-year follow-up, there was no difference in surgical repair versus primary tenodesis relating to patient satisfaction scores (12 very satisfied and 13 satisfied vs 16 very satisfied and 14 satisfied; P = .70), isometric quadriceps strength (95.6% ± 2.8% vs 95.2% ± 6.3%; P = .31), Tegner scores (median [interquartile range], 9 [8-9] vs 9 [8-9]; P = .54), and lower extremity functional scores (73 [72-76] vs 74 [72-75]; P = .41). High patient satisfaction, quadriceps muscle strength, and functional outcome scores were maintained and remained comparable between treatment groups at 2-year follow-up. CONCLUSION Primary tenodesis was associated with reduced time for return to preinjury level of sporting function and decreased risk of injury recurrence when compared with surgical repair for proximal rectus femoris avulsion injuries. There were no differences in patient satisfaction, functional outcome scores, and quadriceps muscle strength between the treatment groups at 1- and 2-year follow-up.
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Affiliation(s)
- Babar Kayani
- Princess Grace Hospital, London, UK.,University College Hospital, London, UK
| | - Sandeep Singh
- Princess Grace Hospital, London, UK.,University College Hospital, London, UK
| | - Justin S Chang
- Princess Grace Hospital, London, UK.,University College Hospital, London, UK
| | - Ahmed A Magan
- Princess Grace Hospital, London, UK.,University College Hospital, London, UK
| | - Ricci Plastow
- Princess Grace Hospital, London, UK.,University College Hospital, London, UK
| | - Fares S Haddad
- Princess Grace Hospital, London, UK.,University College Hospital, London, UK
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9
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Harrington TL, Breedlove GJ, Sharpe JJ. Systematic Review of Nonoperative Functional Protocols for Acute Achilles Ruptures Utilizing a Formal Rehabilitation Protocol Showing Lowest Rerupture Rates. Foot Ankle Spec 2020; 13:508-515. [PMID: 32975140 DOI: 10.1177/1938640020916954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To lay out a comprehensive protocol for practitioners and physical therapists that has the lowest rerupture rates for nonoperative treatment of acute Achilles ruptures. METHOD Relevant articles were searched in PubMed, CINAHL Plus, and Cochrane Library using keyword combinations: nonoperative AND/OR Achilles rupture AND functional AND/OR protocol or functional AND/OR rehabilitation. To be included in the full analysis, the studies had to have detailed functional protocols with physical therapy program details and outcome scores of rupture rates and/or Achilles Tendon Rupture Score (ATRS). We ultimately found 7 articles that fit our inclusion criteria for analysis. All of them had rerupture rates, and 4 had ATRS scores and functional protocols with mention of formal physical therapy programs. RESULTS Lowest rerupture rates were found in strict functional rehabilitation protocols that were full weightbearing in boot immediately at full equinus or 30° plantar flexed. They started active range of motion at 5 to 8 weeks and started formal physical therapy at 10 weeks.Levels of Evidence: Level III: Evidence obtained from well-designed non-experimental descriptive studies.
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Affiliation(s)
- Tara L Harrington
- Folsom Orthopedics and Sports Medicine, Folsom, California (TLH).,Orthopedic Associates of Lake County, Madison, Ohio (GJB).,Orthopedic Associates of Lake County, Concord, Ohio (JJS)
| | - Gerald J Breedlove
- Folsom Orthopedics and Sports Medicine, Folsom, California (TLH).,Orthopedic Associates of Lake County, Madison, Ohio (GJB).,Orthopedic Associates of Lake County, Concord, Ohio (JJS)
| | - Jonathan J Sharpe
- Folsom Orthopedics and Sports Medicine, Folsom, California (TLH).,Orthopedic Associates of Lake County, Madison, Ohio (GJB).,Orthopedic Associates of Lake County, Concord, Ohio (JJS)
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10
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Ayuob A, Kayani B, Haddad FS. Musculotendinous Junction Injuries of the Proximal Biceps Femoris: A Prospective Study of 64 Patients Treated Surgically. Am J Sports Med 2020; 48:1974-1982. [PMID: 32603235 DOI: 10.1177/0363546520926999] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injuries to the hamstring complex most commonly involve the proximal musculotendinous junction of the long head of the biceps femoris (MTJ-BFlh). Nonoperative management of these injuries is associated with prolonged rehabilitation and high risk of recurrence. To our knowledge, the surgical management of acute MTJ-BFlh injuries has not been previously reported. HYPOTHESIS Surgical repair of acute MTJ-BFlh injuries enables return to sporting activity with low risk of recurrence. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 64 patients (42 male and 22 female) undergoing surgical repair of acute MTJ-BFlh injuries were included. Predefined outcomes were recorded at regular intervals after surgery. Mean follow-up time after surgery was 29.2 months (range, 24.0-37.1 months). RESULTS All study patients returned to their preinjury levels of sporting activity. Mean ± SD time from surgical intervention to return to sporting activity was 13.4 ± 5.1 weeks. Three patients had reinjury at the operative site: 1 (1.6%) with MTJ-BFlh injury and 2 (3.2%) with myofascial tears. At 3 months after surgery, patients had improved mean passive straight-leg raise (72.0° ± 11.4° vs 24.1° ± 6.8°; P < .001); increased mean isometric hamstring muscle strength at 0° (84.5 % ± 10.4% vs 25.9% ± 8.9%; P < .001), 15° (89.5% ± 7.3% vs 41.2% ± 9.7%; P < .001), and 45° (93.9% ± 5.1% vs 63.4% ± 7.6%; P < .001); higher mean Lower Extremity Functional Scale scores (71.5 ± 5.0 vs 29.8 ± 6.3; P < .001); and improved mean Marx activity rating scores (9.8 ± 2.2 vs 3.8 ± 1.9; P < .001), as compared with preoperative scores. High patient satisfaction and functional outcome scores were maintained at 1 and 2 years after surgery. CONCLUSION Surgical repair of acute MTJ-BFlh injuries enables return to preinjury level of sporting function with low risk of recurrence at short-term follow-up.
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Affiliation(s)
- Atif Ayuob
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Babar Kayani
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
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11
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Nam IH, Park YU, Cho JH, Lee DH, Min KJ. Comparison Between Early Functional Rehabilitation and Cast Immobilization After Minimally Invasive Repair for an Acute Achilles Tendon Rupture. J Foot Ankle Surg 2019; 58:628-631. [PMID: 31130480 DOI: 10.1053/j.jfas.2018.12.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Indexed: 02/03/2023]
Abstract
The purpose of the present study was to compare the outcomes of patients with Achilles tendon rupture treated with minimally invasive repair and early functional rehabilitation with the outcomes of similar patients treated with cast immobilization. After undergoing minimally invasive surgery, a below-knee splint with the foot in 30° of plantarflexion was applied to each patient for the first week. Patients were then assigned to a cast immobilization group (IG; n = 25) or a functional group (FG; n = 16). Data were collected during outpatient checks at 6 weeks, 3 months, 6 months, and 1 year. Outcomes of interest included range of motion (ROM), heel height, calf circumference, pain and functional score, return to work and light sports activity, and complications. The time interval for return to work in the FG was faster than that in the IG (p = .026). There was no clinically important difference between the 2 groups with regard to heel height, ROM, return to sports, calf circumference, visual analog scale, American Orthopaedic Foot and Ankle Society score, or Achilles tendon Total Rupture Score at every outpatient check except ROM difference at 6 weeks and heel height at 3 months. Rerupture occurred in 2 patients (1 [4%] in the IG and 1 [6.25%] in the FG). Early functional rehabilitation seemed to be as safe as traditional postoperative immobilization with a similar functional result and complications, but it was advantageous for the early phase of rehabilitation only.
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Affiliation(s)
- Il Hyun Nam
- Surgeon, Department of Orthopedic Surgery, Pohang, St. Mary's Hospital, Pohang, Gyeongsangbuk-do, Republic of Korea
| | - Young Uk Park
- Professor, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea.
| | - Jae Ho Cho
- Professor, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Doo Hyung Lee
- Professor, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Kyung Jun Min
- Surgeon, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
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12
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Aujla R, Patel S, Jones A, Bhatia M. Predictors of functional outcome in non-operatively managed Achilles tendon ruptures. Foot Ankle Surg 2018; 24:336-341. [PMID: 29409242 DOI: 10.1016/j.fas.2017.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/11/2017] [Accepted: 03/21/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute Achilles tendon (AT) rupture management remains debatable but non-operative functional regimes are beginning to gain popularity. The aim of this study was to identify predictors of functional outcome in patients with AT ruptures treated non-operatively with an immediate weight bearing functional regime in an orthosis. METHODS Analysis of prospectively gathered data from a local database of all patients treated non-operatively at our institution with an AT rupture was performed. For inclusion in the study patients required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 6 months post injury. The ATRS score was correlated against age, gender, time following rupture, duration (8 or 11 weeks) of treatment in a functional orthoses and complications were recorded. RESULTS 236 patients of average age 49.5 years were included. The mean ATRS on completion of rehabilitation was 74 points. The mean ATRS was significantly lower in the 37 females (65.8) as compared to the 199 males (75.6) (p=0.013). Age inversely affected ATRS with a Pearsons correlation of -0.2. There was no significant difference in the ATRS score when comparing the two different treatment regime durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change significantly after 6 months following rupture treatment completion. CONCLUSION Patients with AT ruptures treated non-operatively with a functional rehabilitation regime demonstrate comparable function to other non-surgical regimes with low re-rupture rates. Increasing age and female gender demonstrate inferior functional outcomes. CLINICAL RELEVANCE Females and increasing age predict poorer functional outcome in acute Achilles tendon ruptures managed in a dynamic full-weight bearing treatment regime.
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Affiliation(s)
- Randeep Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | - Shakil Patel
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Annette Jones
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
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13
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Dean R, Sethi P. A novel method for reducing gap formation in tendon repair. J Orthop 2018; 15:259-263. [PMID: 29657480 DOI: 10.1016/j.jor.2018.01.054] [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: 08/13/2017] [Accepted: 01/14/2018] [Indexed: 10/18/2022] Open
Abstract
Background This study investigates gap formation in tendon repair using a novel tensioning method. Hypothesis The novel stitch will demonstrate less gap formation than the other suture configurations tested. Methods Porcine tendons stitched with classic Krackow stitch configurations were compared to a Krackow stitch modified with a proximal Tension-Assist Loop. Each group was cyclically loaded followed by analysis of the tendon-suture construct for gap formation. Results The Tension-Assist Loop group produced significantly less gap formation than each of the other stitch groups. Conclusion Decreasing early gap formation may be beneficial in allowing early rehabilitation and range of motion.
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Affiliation(s)
- Ryan Dean
- New York Medical College, School of Medicine, United States
| | - Paul Sethi
- ONS Foundation for Clinical Research and Education Inc., 6 Greenwich Office Park, Suite 100, 40 Valley Drive, Greenwich, CT 06831, United States
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14
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Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc 2018; 26:846-853. [PMID: 26410099 DOI: 10.1007/s00167-015-3795-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/15/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair. METHODS A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included. RESULTS One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment. CONCLUSION Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician. LEVEL OF EVIDENCE II.
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15
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Hu Y, Jiang H, Li Q, Li J, Tang X. [Biomechanical study of different suture methods in repairing tendon rupture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:1208-1213. [PMID: 29806322 DOI: 10.7507/1002-1892.201705007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To evaluate the biomechanical property of tendons repaired with the modified Kessler suture combined with " 8" suture, and to provide evidence for the clinical application of this suture methods in repairing acute Achilles tendon rupture. Methods Forty frozen flexor digitorum longus tendons from fresh pork hind leg were randomly assigned into 4 groups, 10 specimens each group. In group A, the tendons were dissected transversely at the midpoint to forming the model of tendon with transversely cutting injury. The tendons in groups B, C, and D were dissected transversely at the midpoint, then a 2 cm segment of tendon from the incision in each side was dissected longitudinally with 1 mm internal to forming " frayed tendon" model. All the tendons were sutured with2-0 non-absorbable suture material with different suturing methods: in group A, the tendons with transversely cutting injury model with Krackow suture, and in the groups B, C, and D with Krackow suture, Kessler suture, and the modified Kessler suture combined with " 8" suture separately. All repaired tendons were fixed onto the biomechanical testing machine. The length, width, and thickness of each side and midpoint of the tendons were recorded, and the cross-sectional area was calculated. The tendons were stretched at a speed of 15 mm/minutes until failure (suture avulsion or rupture). The computer automatically recorded the maximum load, stress, strain, the failure displacement, and the stiffness. These biomechanical parameters of tendons in different groups were analyzed and compared. Results There was no significant difference in the length and cross-sectional area of each tendon among 4 groups ( F=0.245, P=0.863; F=0.094, P=0.963). Two tendons in group B, 1 in group C, and 1 in group D were excluded because of tendon slipping; all tendons in group A and 8 tendons in group B failured due to suture rupture, 9 tendons in group C due to suture slipping, and 9 tendons in group D due to 3 sutures slipping from tendon tissue together. The maximum load, the maximum stress, the maximum strain, the failure displacement, and the stiffness of the tendons between groups A and B showed no significant difference ( P>0.05). The maximum load, the maximum stress, and the stiffness of the tendons in group D were larger than those in both groups B and C ( P<0.05), but no significant difference was found in the maximum strain and the failure displacement between groups B, C, and D ( P>0.05). The maximum load, the maximum stress, the failure displacement, and the stiffness of the tendons in group B were larger than those in group C ( P<0.05), but the difference of maximum strain between groups B and C was not significant ( P>0.05). Conclusion The modified Kessler suture combined with " 8" suture can provide better biomechanical property of the repaired tendon compared with other suture approaches.
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Affiliation(s)
- Yanqing Hu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | | | - Qi Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jian Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Xin Tang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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16
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Suydam SM, Cortes DH, Axe MJ, Snyder-Mackler L, Buchanan TS. Semitendinosus Tendon for ACL Reconstruction: Regrowth and Mechanical Property Recovery. Orthop J Sports Med 2017; 5:2325967117712944. [PMID: 28680900 PMCID: PMC5490845 DOI: 10.1177/2325967117712944] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Semitendinosus/gracilis (STG) tendon autograft has been used effectively for restoring knee stability after anterior cruciate ligament (ACL) rupture. Though ACL reconstruction with STG autograft is an effective surgical technique for return to sports, short-term hamstring strength asymmetries exist after surgery. Although imaging evidence has demonstrated regrowth and reorganization of the semitendinosus (ST) tendon, no studies show whether the regrowth is associated with residual muscle function. Continuous shear wave elastography (cSWE) using an external actuator and high–frame rate ultrasound is a promising technique for evaluating the mechanical properties of regrown tendons in vivo. Purpose: To demonstrate recovery of the mechanical properties of the hamstring tendons after ACL reconstruction using an STG tendon autograft. Study Design: Case series; Level of evidence, 4. Methods: Thirteen patients underwent an STG autograft reconstruction after ACL rupture. Regrowth of the ST tendon was confirmed via b-mode ultrasound between 6 and 24 months postreconstruction. The shear elastic (µ1) and viscosity moduli (µ2) of the ST tendons were ascertained through cSWE using an external actuator and high–frame rate ultrasound. Results: Significant differences in both shear elastic (129.4 vs 73.0 kPa) and viscous moduli (192.6 vs 114.3 Pa·s) existed bilaterally for uninvolved and involved limbs, respectively. Additionally, a positive correlation between time postoperative and shear elasticity was observed (r = 0.60). More than 12 months were required for patients to regain a large percentage of the tendon’s mechanical properties compared with the contralateral side (µ1, 80.6% at >12 months vs 39.9%; µ2, 78.7% at >12 months vs 46.0%). Conclusion: The imaging and elastography data demonstrate tendon regrowth and recovery of functional biomechanical properties with time. The elastic modulus of the recovered tendon indicates the ability to transmit muscle force across the joint and recovery of semitendinosus function after its use for an ACL graft.
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Affiliation(s)
- Stephen M Suydam
- Delaware Rehabilitation Institute, University of Delaware, Newark, Delaware, USA
| | - Daniel H Cortes
- Department of Mechanical and Nuclear Engineering, Pennsylvania State University, State College, Pennsylvania, USA
| | - Michael J Axe
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Lynn Snyder-Mackler
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Thomas S Buchanan
- Delaware Rehabilitation Institute, University of Delaware, Newark, Delaware, USA
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17
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Guzzini M, Lanzetti RM, Proietti L, Mazza D, Fabbri M, Monaco E, Ferri G, Ferretti A. Interlocking horizontal mattress suture versus Kakiuchi technique in repair of Achilles tendon rupture: a biomechanical study. J Orthop Traumatol 2017; 18:251-257. [PMID: 28299456 PMCID: PMC5585091 DOI: 10.1007/s10195-017-0455-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 03/01/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In recent years, the type of surgical treatment for Achilles tendon rupture has been the subject of controversial debate. This biomechanical study evaluates for the first time in literature the ultimate failure load (UFL) of interlocking horizontal mattress (IHM) suture as compared with Kakiuchi suture in Achilles tendon rupture. The hypothesis is that IHM suture can be performed also for Achilles tendon rupture and ensures higher resistance compared with the traditional Kakiuchi suture. MATERIALS AND METHODS Twenty fresh bovine Achilles tendons were obtained. Ten preparations were randomly assigned to each of two different groups: group A (10 specimens) sutured by IHM technique, and group B (10 specimens) sutured by Kakiuchi technique. Each construct was mounted and fixed on a tensile testing machine. Static preconditioning of 50 N was applied for 5 min as initial tensioning to stabilize the mechanical properties of the graft, then a load to failure test was performed at crosshead speed of 500 mm/min. RESULTS Ten specimens were tested for each group. The mean UFL was 228.6 ± 98.6 N in the IHM suture group and 96.57 ± 80.1 N in the Kakiuchi suture group. Statistical analysis showed a significant difference (p < 0.05) with better UFL in the IHM group. In both groups, the failure mode registered in each specimen was suture breakage (rupture of suture thread). CONCLUSIONS IHM suture achieved better UFL compared with Kakiuchi suture in an animal model of Achilles tendon repair. These results seem to support IHM as a valid option in Achilles tendon rupture.
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Affiliation(s)
- Matteo Guzzini
- Azienda Ospedaliera Sant'Andrea Via di Grottarossa, 1035/1039, 00189, Rome, Italy
| | | | - Lorenzo Proietti
- Azienda Ospedaliera Sant'Andrea Via di Grottarossa, 1035/1039, 00189, Rome, Italy.
| | - Daniele Mazza
- Azienda Ospedaliera Sant'Andrea Via di Grottarossa, 1035/1039, 00189, Rome, Italy
| | - Mattia Fabbri
- Azienda Ospedaliera Sant'Andrea Via di Grottarossa, 1035/1039, 00189, Rome, Italy
| | - Edoardo Monaco
- Azienda Ospedaliera Sant'Andrea Via di Grottarossa, 1035/1039, 00189, Rome, Italy
| | - Germano Ferri
- Azienda Ospedaliera Sant'Andrea Via di Grottarossa, 1035/1039, 00189, Rome, Italy
| | - Andrea Ferretti
- Azienda Ospedaliera Sant'Andrea Via di Grottarossa, 1035/1039, 00189, Rome, Italy
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Yammine K, Assi C. Efficacy of repair techniques of the Achilles tendon: A meta-analysis of human cadaveric biomechanical studies. Foot (Edinb) 2017; 30:13-20. [PMID: 28171797 DOI: 10.1016/j.foot.2016.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/18/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Achilles injuries are very common, mainly among young athletes. When indicated, the surgical treatment aims for strong repairs that can resist distraction and consequently ruptures. The majority of the published clinical meta-analyses reported comparisons between broad treatment modalities such as conservative treatment, open, and minimally invasive surgery. METHODS A meta-analysis has been conducted to assess further clinical and biomechanical variables on human cadavers related to the efficacy of Achilles repair. A total of 26 studies with 596 legs met the inclusion criteria. The maximal load to failure was set as the primary outcome. Eleven studies were amenable to meta-analysis. RESULTS In the reinsertion group, the analysis of the single row vs. double row subgroup showed a significantly higher strength for the latter (1.27, 95% CI=0.748-1.806, I2=81%, P<0.0001). In the mid-tendon repair group, the Achillon vs. Krackow sutures and the Bunnell vs. Krackow sutures subgroups showed no difference while the Bunnell and Krakow sutures were significantly stronger than the Kessler sutures (0.96, 95% CI=0.510-1.405, I2=63.3%, P<0.0001 and 1.37, 95% CI=2.286-0.468, I2=83.4%, P=0.003; respectively). CONCLUSIONS The assessment of heterogeneity located variables such as age, suture/material type, number of strands, type of testing machine and software, preloading, ankle position and loading type as potential confounders. The results of this meta-analysis are likely to have a significant impact in clinical practice.
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Affiliation(s)
- Kaissar Yammine
- The Foot and Hand Clinic and The Center for Evidence-Based Anatomy, Sport & Orthopedic Research, Jdeideh Highway, Fouad Yammine Bld., 1st Floor, Beirut, Lebanon.
| | - Chahine Assi
- The Orthopedic Department, Lebanese American University, Lebanon.
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Zhao JG, Meng XH, Liu L, Zeng XT, Kan SL. Early functional rehabilitation versus traditional immobilization for surgical Achilles tendon repair after acute rupture: a systematic review of overlapping meta-analyses. Sci Rep 2017; 7:39871. [PMID: 28054658 PMCID: PMC5215510 DOI: 10.1038/srep39871] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/28/2016] [Indexed: 12/28/2022] Open
Abstract
Several meta-analyses comparing early functional rehabilitation and traditional immobilization following surgical Achilles tendon repair after acute rupture have been published. However, they have led to conflicting conclusions. The aims of this systematic review were to select high-quality meta-analyses from multiple discordant meta-analyses and to provide a postoperative rehabilitation strategy following surgical repair using currently available evidence. We performed a comprehensive search using the PubMed and Embase databases and the Cochrane Library. Assessment of Multiple Systematic Reviews (AMSTAR) instrument was used to assess the methodological quality. Three investigators independently applied the Jadad decision algorithm. Their results were then compared to ensure selection of a meta-analysis that provided the highest quality of evidence. Six meta-analyses met the eligibility criteria. AMSTAR scores ranged from 6 to 10. According to the Jadad decision algorithm, a high-quality meta-analysis with a greater number of RCTs was selected. This meta-analysis showed that early functional rehabilitation was superior to cast immobilization in terms of patient satisfaction and the time to return to pre-morbid sporting levels. There were no differences regarding major complications or the time before return to prior employment and sporting activity. Thus, we recommend early functional rehabilitation as the postoperative strategy for acute Achilles tendon ruptures.
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Affiliation(s)
- Jia-Guo Zhao
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Xiao-Hui Meng
- Department of Orthopaedic Surgery, Yixing Traditional Chinese Medicine Hospital, Jiangsu Province, China
| | - Lin Liu
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xian-Tie Zeng
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Shi-Lian Kan
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
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Takamura M, Yasuda T, Nakano A, Shima H, Neo M. The effect of platelet-rich plasma on Achilles tendon healing in a rabbit model. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:65-72. [PMID: 28027872 PMCID: PMC6197299 DOI: 10.1016/j.aott.2016.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/20/2016] [Accepted: 04/22/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the effects of PRP on Achilles tendon healing in rabbits during the inflammatory, proliferative, and remodeling phases by histological examination and quantitative assessments. METHODS Fifty mature male Japanese albino rabbits with severed Achilles tendons were divided into two equal groups and treated with platelet-rich plasma (PRP) or left untreated. Tendon tissue was harvested at 1, 2, 3, 4, and 6 weeks after treatment, and sections were stained with hematoxylin-eosin and monoclonal antibodies against CD31 and type I collagen. RESULTS Collagen fibers proliferated more densely early after severance, and subsequent remodeling of the collagen fibers and approximation of normal tendinous tissue occurred earlier in the PRP group than in the control group. The fibroblast number was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Similarly, the area ratio of CD31-positive cells was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Positive staining for type I collagen was more intense in the PRP group than in the control group after 3 weeks, indicating tendon maturation. CONCLUSION Administration of PRP shortened the inflammatory phase and promoted tendon healing during the proliferative phase.
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Affiliation(s)
- Masaki Takamura
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan.
| | - Toshito Yasuda
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Atsushi Nakano
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Hiroaki Shima
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
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Aujla R, Kumar A, Bhatia M. Non-surgical treatment of Achilles rupture: Does duration in functional weight bearing orthosis matter? Foot Ankle Surg 2016; 22:254-258. [PMID: 27810024 DOI: 10.1016/j.fas.2015.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/01/2015] [Accepted: 11/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of acute Achilles tendon ruptures is continually being debated. The success of non-surgical regimes is now evident yet there remains a high rate of surgery in the United States of America and Scandinavia. Recent studies have investigated functional outcome rather than complication rates as primary outcome but the current data are still sparse. We aimed to investigate whether there is any difference in functional outcomes between two dynamic regimes of differing durations for acute Achilles tendon ruptures. METHODS The patients in the two groups were matched for age, gender, follow-up duration and mechanism of injury. Forty-four patients were managed in a regime of 11 weeks and another 44 patients for 8 weeks. Demographics, injury details, complications and functional outcome were recorded. The validated Achilles Tendon Rupture Score (ATRS) was used to assess functional outcomes. Minimum follow-up was 1 year. RESULTS The 11-week group had a mean age of 50.8 years (range: 27-80) with 36 (82%) males. The 8-week group had a mean age of 52.0 years (range: 32-77) with 36 (82%) males. The mean ATRS for the 11-week group was 76.0 (range: 8-100). The mean ATRS for the 8-week group was 76.1 (range: 30-100). There were no re-ruptures in the 11-week group and one in the 8-week group. There were three episodes of venous thromboembolism in the 11-week group and four in the 8-week group. CONCLUSION A reduction in duration of dynamic rehabilitation for non-operative treatment of Achilles tendon rupture from 11 weeks to 8 weeks does not lead to a significant detriment in functional outcomes or complication rates.
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Affiliation(s)
- Randeep Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | - Amit Kumar
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
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Barfod KW, Hansen MS, Holmich P, Troelsen A, Kristensen MT. Efficacy of early controlled motion of the ankle compared with no motion after non-operative treatment of an acute Achilles tendon rupture: study protocol for a randomized controlled trial. Trials 2016; 17:564. [PMID: 27894329 PMCID: PMC5127004 DOI: 10.1186/s13063-016-1697-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 11/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early controlled ankle motion is widely used in the non-operative treatment of acute Achilles tendon rupture, though its safety and efficacy have never been investigated in a randomized setup. The objectives of this study are to investigate if early controlled motion of the ankle affects functional and patient-reported outcomes. METHODS/DESIGN The study is performed as a blinded, randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients aged from 18 to 70 years are eligible for inclusion. The intervention group performs early controlled motion of the ankle in weeks 3-8 after rupture. The control group is immobilized. In total, 130 patients will be included from one big orthopedic center over a period of 2½ years. The primary outcome is the patient-reported Achilles tendon Total Rupture Score evaluated at 12 months post-injury. Secondary outcome measures are the heel-rise work test, Achilles tendon elongation, and the rate of re-rupture. The primary analysis will be conducted as intention-to-treat analyses. DISCUSSION This trial is the first to investigate the safety and efficacy of early controlled motion in the treatment of acute Achilles tendon rupture in a randomized setup. The study uses the patient-reported outcome measure, the Achilles tendon Total Rupture Score, as the primary endpoint, as it is believed to be the best surrogate measure for the tendon's actual capability to function in everyday life. TRIAL REGISTRATION ClinicalTrials.gov: NCT02015364 . Registered on 13 December 2013.
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Affiliation(s)
- Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark.
| | - Maria Swennergren Hansen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark
| | - Per Holmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark
| | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark
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Biomechanical comparison of three methods for distal Achilles tendon reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:3756-60. [PMID: 25026935 DOI: 10.1007/s00167-014-3176-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the load at failure and stiffness associated with three surgical techniques for distal Achilles tendon reconstruction (AT). METHODS Nine matched pairs of fresh-frozen human cadaveric ATs were divided into three groups. Distal AT reconstruction was performed using suture anchors or one of two lengths of tendon overlap (10 or 5 mm). Each tendon was loaded to failure. The load at failure (N), stiffness (N/mm), and mode of failure were recorded. Differences in load at failure and stiffness were analysed. RESULTS Mean load at failure was significantly higher in the 10-mm group than in the 5-mm group (p < 0.05) or the suture-anchor group (p < 0.05). Load at failure did not differ significantly between the suture-anchor and 5-mm group, and stiffness did not differ significantly between any two groups. In the 10- and 5-mm groups, failure was caused by the grafts pulling out through the substance of the AT. Modes of failure varied in the suture-anchor group. CONCLUSIONS The load at failure was higher in the 10-mm group than in the 5-mm and suture-anchor groups. Although all three surgical techniques provide sufficient primary load-bearing ability, the 10-mm tendon-overlap technique may be more conducive to early post-operative rehabilitation.
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Sonnery-Cottet B, Daggett M, Gardon R, Pupim B, Clechet J, Thaunat M. Surgical Management of Recurrent Musculotendinous Hamstring Injury in Professional Athletes. Orthop J Sports Med 2015; 3:2325967115606393. [PMID: 26535376 PMCID: PMC4622291 DOI: 10.1177/2325967115606393] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hamstring injury is the most common muscular lesion in athletes. The conservative treatment is well described, and surgical management is often indicated for proximal tendinous avulsions. To our knowledge, no surgical treatment has been proposed for failure of conservative treatment in musculotendinous hamstring lesions. PURPOSE To describe the surgical management of proximal and distal hamstring musculotendinous junction lesions in professional athletes after failure of conservative treatment. STUDY DESIGN Case series; Level of evidence, 4. METHODS A consecutive series of 10 professional athletes, including 4 soccer players, 4 rugby players, and 2 handball players, underwent surgical intervention between October 2010 and June 2014 for the treatment of recurrent musculotendinous hamstring injuries. All athletes had failed at least 3 months of conservative treatment for a recurrent musculotendinous hamstring injury. Surgical resection of the musculotendinous scar tissue was performed using a longitudinal muscular suture. Lower Extremity Functional Scale (LEFS) and Marx scores were obtained at the 3-month follow-up, and a final phone interview was completed to determine recurrence of hamstring injury and return to previous level of play. RESULTS The mean age at surgery was 25.2 years (range, 19-35 years). The musculotendinous hamstring lesions involved 8 semitendinosus and 2 biceps femoris, with 6 injuries located proximally and 4 distally. Conservative treatment lasted a mean 5.1 months (range, 3-9 months) after last recurrence, and the patients had an average of 2.7 (range, 2-5) separate incidents of injury recurrence before surgical intervention was decided upon. At the 3-month follow-up, all patients had Marx activity scores of 16 and LEFS scores of 80. All 10 patients returned to the same level of play at a mean 3.4 months (range, 2-5 months). At a mean follow-up of 28.7 months, none of the athletes had suffered a recurrence. No surgical complication was encountered. CONCLUSION In cases of failed conservative treatment of musculotendinous hamstring lesions, surgical intervention may be a viable treatment option in professional athletes and allows the patient to return to the same level of play.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France
| | - Matt Daggett
- Kansas City University, Kansas City, Missouri, USA
| | - Roland Gardon
- Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France
| | - Barbara Pupim
- Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France
| | - Julien Clechet
- Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France
| | - Mathieu Thaunat
- Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France
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Zietek P, Karaczun M, Kruk B, Szczypior K. Percutaneous, Minimally Invasive Repair of Traumatic and Simultaneous Rupture of Both Achilles Tendons: A Case Report. J Foot Ankle Surg 2015; 55:642-4. [PMID: 26002678 DOI: 10.1053/j.jfas.2015.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Indexed: 02/03/2023]
Abstract
Achilles injury is a common musculoskeletal disorder. Bilateral rupture of the Achilles tendon, however, is much less common and usually occurs spontaneously. Complete, traumatic, and bilateral ruptures are rare and typically require long periods of immobilization before the patient can return to full weightbearing. A 52-year-old male was hospitalized for bilateral traumatic rupture to both Achilles tendons. No risk factors for tendon rupture were found. Blood samples revealed no peripheral blood pathologic features. Both tendons were repaired with percutaneous, minimally invasive surgery using the Achillon(®) tendon suture system. Rehabilitation was begun 4 weeks later. An ankle-foot orthosis was prescribed to provide ankle support with an adjustable range of movement, and active plantar flexion was set at 0° to 30°. The patient remained non-weightbearing with the ankle-foot orthosis device and performed active range-of-motion exercises. At 8 weeks after surgery, we recommended that he begin walking with partial weightbearing using a foot-tibial orthosis with the range of motion set to 45° plantar flexion and 15° dorsiflexion. At 10 weeks postoperatively, he was encouraged to return to full weightbearing on both feet. Beginning rehabilitation as soon as possible after minimally invasive surgery, compared with 6 weeks of immobilization after surgery, provided a rapid resumption to full weightbearing. We emphasize the clinical importance of a safe, simple treatment program that can be followed for a patient with damage to the Achilles tendons. To our knowledge, ours is the first report of minimally invasive repair of bilateral simultaneous traumatic rupture of the Achilles tendon.
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Affiliation(s)
- Pawel Zietek
- Orthopedist, Department of Orthopaedics and Traumatology, Pomeranian Medical University, Szczecin, Poland.
| | - Maciej Karaczun
- Orthopedist, Department of Orthopaedics and Traumatology, Pomeranian Medical University, Szczecin, Poland
| | - Bartosz Kruk
- Orthopedist, Department of Orthopaedics and Traumatology, Pomeranian Medical University, Szczecin, Poland
| | - Karina Szczypior
- Physiotherapist, Department of Orthopaedics and Traumatology, Pomeranian Medical University, Szczecin, Poland
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Domeij-Arverud E, Labruto F, Latifi A, Nilsson G, Edman G, Ackermann PW. Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation. Bone Joint J 2015; 97-B:675-80. [DOI: 10.1302/0301-620x.97b5.34581] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Deep vein thrombosis is a common complication of immobilising the lower limb after surgery. We hypothesised that intermittent pneumatic compression (IPC) therapy in outpatients who had undergone surgical repair of acute ruptures of the Achilles tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of the Achilles tendon were randomised to either treatment with IPC for six hours per day (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively, the incidence of deep vein thrombosis was assessed using blinded, double-reported compression duplex ultrasound. At this point, IPC was discontinued and all patients were immobilised in an orthosis for a further four weeks. At six weeks post-operatively, a second compression duplex ultrasound scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in the treated group and 37% in the control group (p = 0.042). Age over 39 years was found to be a strong risk factor for deep vein thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI) 2.14 to 10.96). Treatment with IPC, corrected for age differences between groups, reduced the risk of deep vein thrombosis at the two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks, the incidence of deep vein thrombosis was 52% in the treated group and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC appears to be an effective method of reducing the risk of deep vein thrombosis in the early stages of post-operative immobilisation of outpatients. Further research is necessary to elucidate whether it can confer similar benefits over longer periods of immobilisation and in a more heterogeneous group of patients. Cite this article: Bone Joint J 2015;97-B:675–80.
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Affiliation(s)
| | - F. Labruto
- Karolinska Institutet, Stockholm, 171
76, Sweden
| | - A. Latifi
- Karolinska Institutet, Stockholm, 171
76, Sweden
| | - G. Nilsson
- Karolinska Institutet, Stockholm, 171
76, Sweden
| | - G. Edman
- Tiohundra Hospital, SE-761
29, Norrtälje, Sweden
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27
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Guss D, Smith JT, Chiodo CP. Acute Achilles Tendon Rupture: A Critical Analysis Review. JBJS Rev 2015; 3:01874474-201504000-00002. [PMID: 27490254 DOI: 10.2106/jbjs.rvw.n.00015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Daniel Guss
- MGM Comprehensive Foot and Ankle Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - Jeremy T Smith
- Brigham Foot and Ankle Center, Department of Orthopaedic Surgery, Brigham and Women's Faulkner Hospital, 1153 Centre Street, Suite 56, Boston, MA 02130
| | - Christopher P Chiodo
- Brigham Foot and Ankle Center, Department of Orthopaedic Surgery, Brigham and Women's Faulkner Hospital, 1153 Centre Street, Suite 56, Boston, MA 02130
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Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. Am J Sports Med 2015; 43:1008-16. [PMID: 24793572 DOI: 10.1177/0363546514531014] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The choice of rehabilitation management after the surgical repair of acute Achilles tendon (AT) ruptures remains controversial because of insufficient clinical evidence. The current study analyzes the postoperative rehabilitation of AT ruptures based on the current clinical evidence. PURPOSE To identify and analyze the high-level clinical evidence regarding postoperative rehabilitation after the surgical repair of AT ruptures. Subgroup analyses were also performed to obtain more reliable and specific results. STUDY DESIGN Meta-analysis. METHODS The studies were retrieved by searching the Medline, Embase, and Cochrane databases through the OVID retrieval engine from 1990 to August 14, 2013. Two independent reviewers critically reviewed the studies using preset inclusion and exclusion criteria. The quality of the eligible studies was assessed by the Cochrane 12-item scale. All included studies were summarized, and their data were extracted. Subgroup analyses were performed according to the different protocols of early functional rehabilitation. RESULTS Nine studies, consisting of 6 randomized controlled trials and 3 quasi-randomized studies, were ultimately included. A total of 402 patients were identified. Six of the included studies utilized early weightbearing combined with early ankle motion exercises, while the other 3 only employed early ankle motion exercises. The subgroup analyses demonstrated that 11 of the 15 functional outcome measurements were significantly superior for patients who underwent both early weightbearing and ankle motion exercises than for those who underwent conventional cast immobilization. Similar rates of reruptures (odds ratio [OR], 1.36; 95% CI, 0.38-4.91; P = .64) and major complications (OR, 0.67; 95% CI, 0.24-1.87; P = .44) as well as a significantly lower rate of minor complications (OR, 0.51; 95% CI, 0.27-0.95; P = .03) were also observed in this early functional rehabilitation group. For the patients who solely performed early ankle motion exercises, only 2 of the 14 functional measurements were observed to be significantly superior to immobilization. There were also no significant differences in the rates of reruptures (OR, 0.47; 95% CI, 0.08-2.70; P = .40) and other complications (OR, 1.09; 95% CI, 0.41-2.92; P = .86) between the 2 groups. CONCLUSION Postoperative early weightbearing combined with early ankle motion exercises is associated with a lower minor complication rate and achieves superior and more rapid functional recovery than conventional immobilization after surgical AT repair. In contrast, few advantages were identified when only early ankle motion exercises were applied.
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Affiliation(s)
- Jiazhang Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Chao Zhang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Li Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
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Healing of human Achilles tendon ruptures: radiodensity reflects mechanical properties. Knee Surg Sports Traumatol Arthrosc 2015; 23:884-9. [PMID: 24162760 DOI: 10.1007/s00167-013-2720-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 10/08/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE This study tests the idea of using radiodensity from computed tomography to quantitatively evaluate the healing of ruptured Achilles tendons. METHODS The radiodensity of the healing tendons in sixty-five patients who were treated for Achilles tendon rupture was measured. The hypothesis was that density would correlate with an estimate for e-modulus, derived from strain, measured by radiostereometry with different mechanical loadings. RESULTS Radiodensity 7 weeks after injury was decreased to 67 % (SD 11) of the contralateral, uninjured tendon. There was no improvement in radiodensity from 7 to 19 weeks, whereas at 1 year, it had increased to 106 % (SD 7). Only 2 of 52 measured values at 1 year were lower than the highest value at 19 weeks, i.e. there was minimal overlap. The variation in radiodensity could explain 80 % of the variation in e-modulus, but radiodensity correlated only weakly with e-modulus at each time point separately. At 1 year, both radiodensity and e-modulus correlated with functional results, although weakly. CONCLUSIONS From 19 weeks onwards, radiodensity appears to reflect mechanical properties of the tendon and might to some extent predict the final outcome. Radiodensity at 7 weeks is difficult to interpret, probably because it reflects both callus and damaged tissues.
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Hahn JM, Inceoğlu S, Wongworawat MD. Biomechanical comparison of Krackow locking stitch versus nonlocking loop stitch with varying number of throws. Am J Sports Med 2014; 42:3003-8. [PMID: 25269654 DOI: 10.1177/0363546514550989] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Common suture configuration techniques used for ligament and tendon grafts and repair are the Krackow locking stitch and a nonlocking loop stitch, such as a whipstitch. Clinically, the preferences of orthopaedic surgeons vary. HYPOTHESIS The Krackow locking stitch and the nonlocking whipstitch, with varying suture loops, produce different biomechanical and physical effects on the tendon end. STUDY DESIGN Controlled laboratory study. METHODS A total of 52 fresh-frozen porcine flexor digitorum tendons were used and assigned into 10 groups. Two stitch configurations (Krackow stitch [K] and whipstitch [W]) with varying number of loops (2 throws, n = 6; 4 throws, n = 5; 6 throws, n = 5; 8 throws, n = 5; 10 throws, n = 5) were tested. No. 2 FiberWire was used. Each sample was preloaded to 5 N and then cyclically loaded for 200 cycles to 200 N at 1 Hz, and then the tendon-suture construct was analyzed for gap formation, tendon elongation, and tendon end width. Next, each tendon was loaded to failure, and ultimate strength and mode of failure were recorded. Data were evaluated with 2-way analysis of variance. RESULTS For gap formation, the Krackow stitch produced less gap compared with the whipstitch (15.2 ± 4.0 mm [K] vs 18.9 ± 6.8 mm [W]; P = .012). Gap formation was larger when the number of loops increased from 2 to ≥6 (P = .015). For elongation, the Krackow technique increased the tendon length after cyclic loading. In contrast, the whipstitch was noted to shorten the length of the tendon (1.17 ± 0.97 mm [K] vs -0.14 ± 1.13 mm [W]; P < .001). For tendon end width, the Krackow better preserved the transverse width (-0.64 ± 0.81 mm [K] vs -1.39 ± 0.64 mm [W]; P = .001). Both stitch types had similar ultimate strength (322.1 ± 20.3 N [K] vs 319.7 ± 20.4 N [W]; P = .676) and modes of failure (all by suture breakage; therefore, no statistical calculation was performed). There was no statistical difference in tendon elongation, width, failure load, or mode regardless of the number of throws. CONCLUSION/CLINICAL RELEVANCE Given the finding that the Krackow suture had less gap formation and better preservation of tendon architecture (length and width) compared with the whipstitch, coupled with the finding that ultimate strength is similar with both types of sutures, the Krackow stitch is recommended for tendon reconstruction when these parameters are important.
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Affiliation(s)
- Joseph Minsoo Hahn
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, California, USA
| | - Serkan Inceoğlu
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, California, USA
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Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture - Development of an evidence-based treatment protocol. Injury 2014; 45:1782-90. [PMID: 25059505 DOI: 10.1016/j.injury.2014.06.022] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/29/2014] [Indexed: 02/02/2023]
Abstract
The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period. Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently, the aim of our study was to systematically search the evidence available and define a precise rehabilitation programme after operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence. We performed a systematic literature search in Medline, Embase and Cochrane library. We identified twelve randomized controlled trials comparing different treatment regimes after operative repair of the Achilles tendon. Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity. Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens time to return to work and sports significantly. Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation. No study found an increased rerupture rate for the more progressive treatment. In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied.
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Affiliation(s)
- Mareen Brumann
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich
| | - Sebastian F Baumbach
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich
| | - Wolf Mutschler
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich
| | - Hans Polzer
- Munich University Hospital, Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstr. 20, 80336 Munich.
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Yang G, Rothrauff BB, Tuan RS. Tendon and ligament regeneration and repair: clinical relevance and developmental paradigm. ACTA ACUST UNITED AC 2014; 99:203-222. [PMID: 24078497 DOI: 10.1002/bdrc.21041] [Citation(s) in RCA: 271] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 07/27/2013] [Accepted: 07/27/2013] [Indexed: 12/18/2022]
Abstract
As dense connective tissues connecting bone to muscle and bone to bone, respectively, tendon and ligament (T/L) arise from the somitic mesoderm, originating in a recently discovered somitic compartment, the syndetome. Inductive signals from the adjacent sclerotome and myotome upregulate expression of Scleraxis, a key transcription factor for tenogenic and ligamentogenic differentiation. Understanding T/L development is critical to establishing a knowledge base for improving the healing and repair of T/L injuries, a high-burden disease due to the intrinsically poor natural healing response. Current treatment of the three most common tendon injuries-tearing of the rotator cuff of the shoulder, flexor tendon of the hand, and Achilles tendon-include mostly surgical repair and/or conservative approaches, including biophysical modalities such as rehabilitation and cryotherapy. Unfortunately, the fibrovascular scar formed during healing possesses inferior mechanical and biochemical properties, resulting in compromised tissue functionality. Regenerative approaches have sought to augment the injured tissue with cells, scaffolds, bioactive agents, and mechanical stimulation to improve the natural healing response. The key challenges in restoring full T/L function following injury include optimal combination of these biological agents as well as their delivery to the injury site. A greater understanding of the molecular mechanisms involved in T/L development and natural healing, coupled with the capability of producing complex biomaterials to deliver multiple biofactors with high spatiotemporal resolution and specificity, should lead to regenerative procedures that more closely recapitulate T/L morphogenesis, thereby offering future patients the prospect of T/L regeneration, as opposed to simple tissue repair.
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Affiliation(s)
- Guang Yang
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA
| | - Benjamin B Rothrauff
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA
| | - Rocky S Tuan
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA
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Huri G, Biçer ÖS, Ozgözen L, Uçar Y, Garbis NG, Hyun YS. A novel repair method for the treatment of acute Achilles tendon rupture with minimally invasive approach using button implant: a biomechanical study. Foot Ankle Surg 2013; 19:261-6. [PMID: 24095235 DOI: 10.1016/j.fas.2013.06.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/15/2013] [Accepted: 06/25/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Minimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low rate of complications. However there are still controversies about optimal technique. In this study we aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair technique and evaluate its biomechanical properties comparing with native tendon and Krackow technique. METHODS 27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including native tendons. Unidirectional tensile loading to failure was performed at 25mm/min. Biomechanicalproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and Young'smodulus (GPa) was measured for each group. All groups were compared with each other using one-wayANOVA followed by the Tukey HSD multiple comparison test (a=0.05). RESULTS The average peak force (N) to failure of group 1 and group 2 and control group was 415.6±57.6, 268.1±65.2 and 704.5±85.8, respectively. There was no statistically significant difference between native tendon and group 1 for the amount elongation at failure (p>0.05). CONCLUSIONS Regarding the results, we concluded that Endobutton-assisted modified Bunnell technique provides stronger fixation than conventional techniques. It may allow early range of motion and can be easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality tendon at the distal part of rupture. LEVEL OF EVIDENCE Level II, Biomechanical research study.
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Affiliation(s)
- Gazi Huri
- Department of Orthopaedic and Traumatology Surgery, Cukurova University, Adana, Turkey; Department of Orthopaedics and Traumatology Surgery, Division of Sport Medicine, Johns Hopkins University, Baltimore, MD, USA
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Abstract
The incidence of acute Achilles tendon ruptures is on the rise. This is thought to be due to the increasing number of middle-aged persons participating in athletic and/or strenuous activity. Ruptures of the Achilles tendon can be severely debilitating, with deficits seen years after the initial incident. Also, these injuries can have substantial socioeconomic impacts regardless of the treatment selected. Debate continues over the optimal treatment of Achilles tendon ruptures, especially the argument whether to treat patients nonoperatively or surgically. Newer evidence shows that functional rehabilitation, including early weight-bearing, should be an integral part of successful treatment of acute Achilles ruptures. Further research is needed to further investigate the ideal treatment and rehabilitation protocols.
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Affiliation(s)
- David Pedowitz
- />Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Greg Kirwan
- />Premier Orthopaedics, Chester County Orthopaedic Associates, 915 Old Fern Hill Road, (Suite 1 B-A), West Chester, PA 19380 USA
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Domeij-Arverud E, Latifi A, Labruto F, Nilsson G, Ackermann PW. Can foot compression under a plaster cast prevent deep-vein thrombosis during lower limb immobilisation? Bone Joint J 2013; 95-B:1227-31. [PMID: 23997137 DOI: 10.1302/0301-620x.95b9.31162] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (ϕ = 0.71; p = 0.019), leading to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application.
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Affiliation(s)
- E Domeij-Arverud
- Institution of Molecular Medicine and Surgery, Karolinska Institutet, 171 77, Stockholm, Sweden.
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Carmont MR, Heaver C, Pradhan A, Mei-Dan O, Gravare Silbernagel K. Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair. Knee Surg Sports Traumatol Arthrosc 2013; 21:1361-8. [PMID: 23377798 DOI: 10.1007/s00167-013-2423-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 01/21/2013] [Indexed: 12/28/2022]
Abstract
PURPOSE Recent meta-analyses have shown reduced re-rupture rates for the surgical management of Achilles ruptures. However, percutaneous repair has been demonstrated to lead to improved function and patient satisfaction but greater complications than open repair. In the current economic climate, it is reasonable to consider the financial cost of rupture management for both the patient and the provider. The cost-effectiveness of operative treatment of ruptures of the Achilles tendon was determined based upon theatre occupancy, clinic attendance and cast changes, operative complications and functional assessment score. METHODS The cost-effectiveness of the surgical management of Achilles tendon ruptures between 2005 and 2011 in our unit was audited by comparing 49 patients receiving percutaneous repair to 35 patients whom had open repairs. RESULTS There was no significant difference in complications between the two surgical techniques: (Open vs. Percutaneous) overall rates 14.3 versus 10.4 %: infection; 2.7 versus 2.0 %, transient sural nerve damage: 5.6 versus 8.1 %, wound breakdown: 2.8 versus 0.0 %, re-rupture: 2.8 versus 2.0 %. Achilles Total Rupture Scores (ATRS) were comparable [Open 89 (65-100) at 49 months vs. Percutaneous 88.8 (33-100) at 12 months (n.s.)]. Theatre occupancy (P < 0.00) and hospital stay (P < 0.00) were significantly longer with open repair [43 min (26-70) and 2.9 days (0-4)] compared to percutaneous repair [15 min (12-43) and 1.2 days (0-2)]. Excluding the costs of running the operating theatre, we have estimated the costs of surgery for open repair to be £ 935 and percutaneous repair to be £ 574. CONCLUSIONS This study suggests that percutaneous repair of the Achilles tendon resulted in reduced costs and yet had comparable outcome and complications rates to open repair in surgical management of the Achilles tendon. Percutaneous repair should be considered as the primary method of cost-effective surgical management of Achilles tendon rupture.
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Affiliation(s)
- M R Carmont
- The Department of Orthopaedic Surgery, Princess Royal Hospital, Telford, Shropshire, TF1 6TF, UK.
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37
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Comin J, Malliaras P, Baquie P, Barbour T, Connell D. Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med 2013; 41:111-5. [PMID: 23111807 DOI: 10.1177/0363546512463679] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The hamstring muscles are the most commonly injured muscle group in many different sports. Recovery time is often unpredictable and prolonged, and recurrent injury is common. HYPOTHESIS Hamstring injuries that disrupt the central tendon enclosed within the muscle belly require a longer recovery time than do injuries involving only muscle, epimysial fascia, or the musculotendinous junction. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Injury records from professional sports teams were reviewed to determine the length of recovery from each hamstring injury that occurred over a 24-month period. The integrity of the central tendon on magnetic resonance imaging (MRI) was retrospectively reviewed for each case. The association between central tendon disruption on MRI and recovery time was determined. RESULTS There were 62 hamstring injuries included for analysis; 45 (72%) involved the biceps femoris, 11 (18%) involved the semimembranosus, and 6 (10%) involved the semitendinosus. Central tendon disruption was identified in 12 (45%) of the biceps femoris injuries and in none of the injuries to the other 2 muscles. Three of these injuries were treated surgically, with a median recovery time of 91 days. The median (interquartile range [IQR]) recovery times for those remaining biceps femoris injuries with and without central tendon disruption were 21 days (IQR, 9-28) and 72 days (IQR, 42-109), respectively (P < .01). CONCLUSION Disruption of the central tendon in injuries to the biceps femoris results in a significantly longer recovery time than injuries that do not disrupt the central tendon. This highlights the distinction between injury to the hamstring muscle and injury to the hamstring tendon, which is underappreciated as being a distinct entity when injury involves the enclosed central portion of the tendon.
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Affiliation(s)
- Jules Comin
- Imaging @ Olympic Park, Melbourne, Australia.
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Plate JF, Wiggins WF, Haubruck P, Scott AT, Smith TL, Saul KR, Mannava S. Normal aging alters in vivo passive biomechanical response of the rat gastrocnemius-Achilles muscle-tendon unit. J Biomech 2012; 46:450-5. [PMID: 23245562 DOI: 10.1016/j.jbiomech.2012.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 10/29/2012] [Accepted: 11/01/2012] [Indexed: 10/27/2022]
Abstract
Predisposition to Achilles tendon (AT) ruptures in middle-aged individuals may be associated with age-related changes to inherent passive biomechanical properties of the gastrocnemius-Achilles (GC-AT) muscle-tendon unit, due to known muscle-tendon structural changes in normal aging. The goal of this study was to determine whether the passive biomechanical response of the GC-AT muscle-tendon unit was altered with age in 6 young (8 months) and 6 middle-aged (24 months) F344xBN hybrid rats from the National Institute on Aging colony. Fung's quasilinear viscoelastic (QLV) model was used to determine in vivo history and time-dependent load-relaxation response of the GC-AT. Effective stiffness and modulus were also estimated using linear regression analysis. Fung's QLV revealed a significantly decreased magnitude of the relaxation response (parameter C, p=0.026) in middle-aged animals compared to young animals (0.108±0.007 vs. 0.144±0.015), with similar time-dependent viscous GC-AT properties (τ(1), τ(2)). The product of elastic parameters (A*B), which represents the initial slope of the elastic response, was significantly increased by 50% in middle-aged rats (p=0.014). Estimated GC-AT stiffness increased 28% at peak tensions in middle-aged rats (2.7±0.2 N/mm) compared to young rats (1.9±0.2 N/mm; p=0.036). While the limitations of this animal model must be considered, the changes we describe could be associated with the observation that GC-AT pathology and injury is more common in middle-aged individuals. Further studies are necessary to characterize the load-to-failure behavior of AT in middle-aged compared to young animals.
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Affiliation(s)
- Johannes F Plate
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157-1070, USA.
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Martín-Vivaldi Jiménez A, Molina Rueda MJ, Molina Rueda F. Re: Results of accelerated postoperative rehabilitation using novel "suture frame" repair of Achilles tendon rupture. J Foot Ankle Surg 2012; 51:704; author reply 704. [PMID: 22916739 DOI: 10.1053/j.jfas.2012.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Indexed: 02/03/2023]
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40
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Ortiz C, Wagner E, Mocoçain P, Labarca G, Keller A, Del Buono A, Maffulli N. Biomechanical comparison of four methods of repair of the Achilles tendon. ACTA ACUST UNITED AC 2012; 94:663-7. [DOI: 10.1302/0301-620x.94b5.27642] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p < 0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot. The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.
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Affiliation(s)
- C. Ortiz
- Clinica Alemana de Santiago, Orthopedics
and Traumatology Department, 6th floor, Vitacura
5951, Santiago, Chile
| | - E. Wagner
- Clinica Alemana de Santiago, Orthopedics
and Traumatology Department, 6th floor, Vitacura
5951, Santiago, Chile
| | - P. Mocoçain
- Clinica Alemana de Santiago, Orthopedics
and Traumatology Department, 6th floor, Vitacura
5951, Santiago, Chile
| | - G. Labarca
- Clinica Alemana de Santiago, Orthopedics
and Traumatology Department, 6th floor, Vitacura
5951, Santiago, Chile
| | - A. Keller
- Clinica Alemana de Santiago, Orthopedics
and Traumatology Department, 6th floor, Vitacura
5951, Santiago, Chile
| | - A. Del Buono
- Campus Biomedico, University of Rome, Department
of Orthopaedic and Trauma Surgery, Via Álvaro
del Portillo 21, 00128 Rome, Italy
| | - N. Maffulli
- Centre for Sports and Exercise Medicine,
Barts and The London School of Medicine and Dentistry, Mile
End Hospital, 275 Bancroft Road, London
E1 4DG, UK
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