Management of acute Achilles tendon ruptures: A review

Biocompatible and stretchable chitosan piezoelectric gel with antibacterial capability and motion monitoring function for Achilles tendon rupture treatment

Achilles tendon rupture is a common and serious condition that remains a challenge in the restoration of tendon structure and function. The design and use of high-performance piezoelectric materials serve as an effective solution to enhance repair outcomes, shorten recovery times, and reduce the risk of recurrence. In this study, we prepared a chitosan piezoelectric gel (CSPG) as an organic polymer with excellent biocompatibility, stretchability, and piezoelectric properties as well as excellent antibacterial properties. In vitro experiments showed that CSPG, which induces a piezoelectric effect, can inhibit bacterial growth, promote cell proliferation and migration, upregulate the expression of tendon-related genes, and inhibit the expression of inflammation-related genes. In vivo experiments showed improved outcomes for Achilles tendon repair following CSPG intervention, as evidenced by enhanced animal mobility and improved mechanical test results. In addition, the CSPG exhibited sensory functions capable of monitoring temperature and motion, providing timely feedback on repair efficacy. In summary, this study not only successfully prepared a multifunctional piezoelectric material that can effectively promote Achilles tendon rupture repair and regeneration and control inflammatory response, it also possesses antibacterial and sensing functions, thus offering a new strategy for Achilles tendon rupture repair.

iTRAQ-Based Proteomic Analysis of Spontaneous Achilles Tendon Rupture

Spontaneous Achilles tendon rupture (SATR) predominantly affects middle-aged and elderly individuals with chronic injuries. However, the exact cause and mechanism of SATR remain elusive, and potential therapeutic intervention or prevention is still insufficient. The present study aimed to uncover the key pathological molecules by using iTRAQ proteomics. The results identified 2432 candidate proteins in SATR patients using iTRAQ proteomic analysis. A total of 307 differentially expressed proteins (DEPs) were identified and linked to 211 KEGG signaling pathways including Coronavirus disease (COVID-19), focal adhesion, and ribosomes. GO enrichment analysis highlighted significant enrichment in processes such as biological adhesion, ossification, lipid (APOA4) processes, and extracellular matrix (ECM) organization (collagen). PPI network analysis identified hub genes such as serum albumin (ALB), fibronectin (FN1), and actin cytoplasmic 1. The WB analysis confirmed that FN1 and the receptor for activated C kinase (RACK1) were downregulated in the SATR tendon. Immunohistochemical staining revealed that collagen I and III were suppressed, while collagen II and APOA4 expression were higher in the SATR pathological tissue (P < 0.05). However, the primary cultured tenocytes (PCTs) from SATR patients showed enhanced proliferation and, consistent with tissue staining, reduced collagen I and III and increased collagen II. Our findings reveal vital targets and pathways in SATR's etiological progression, offering a new perspective on the diagnosis, treatment, and prognosis of this complex disorder.

Mini-open versus percutaneous surgical repair for acute Achilles tendon rupture: a systematic review and meta-analysis

PURPOSE

To compare the clinical outcomes and complications of mini-open (MOT) and percutaneous techniques (PT) in the surgical repair of acute Achilles tendon rupture (AATR).

METHODS

We systematically searched PubMed, Scopus, Web of Science, Clinical Trials, and the Cochrane Library for studies comparing MOT with PT for AATR. We assessed functional outcomes, complication rates, and operation time. Statistical analyses were performed using RevMan Web. Odds ratios (ORs) and mean difference (MD) with 95% confidence intervals (CIs) were pooled with a fixed-effects model for dichotomous and continuous endpoints, respectively. Heterogeneity was evaluated with I2 statistics.

RESULTS

Eight studies, comprising 484 patients, were included, of whom 226 (46%) underwent MOT. MOT was associated with a significantly lower re-rupture rate (1.48% vs. 6.11%; OR 0.28; 95% CI 0.09-0.86; p = 0.03; I2 = 6%) and sural nerve injury rate (0.57% vs. 5.64%; OR 0.24; 95% CI 0.07-0.81; p = 0.02; I2 = 0%). No significant differences were observed in venous thrombosis (OR 0.81; 95% CI 0.17-3.94; p = 0.33; I2 = 0%), wound infection (OR 0.56; 95% CI 0.12-2.62; p = 0.46; I2 = 0%), or operation time (MD 1.83 min; 95% CI -1.13-4.79; p = 0.23; I2 = 88%). Functional outcomes showed higher American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores in the MOT group (MD 1.52 points; 95% CI 0.62-2.42; p = 0.001; I2 = 3%), while (Achilles Tendon Total Rupture Score) ATRS, time to return to activities, and ankle plantar and dorsiflexion were comparable.

CONCLUSIONS

MOT for AATR repair seems to reduce re-ruptures and sural nerve injuries while improving AOFAS scores, with no significant differences in other complications compared to PT. These findings suggest that the MOT may offer a safer and equally effective alternative to PT for AATR.

The Fragility of Statistically Significant Binary Outcomes for Treating Achilles Tendinopathy: A Systematic Review of Randomized Trials

Background

Randomized controlled trials (RCTs) are the gold standard for treatment efficacy, but foot and ankle RCTs are often small or inconsistent. The Fragility Index (FI) evaluates the stability of significant findings. This study assessed the fragility of RCT outcomes for Achilles tendon pathology (ATP) interventions.

Methods

This systematic review queried PubMed up to May 14, 2024, for RCTs on ATP interventions. RCTs with significant binary outcomes were included. Two reviewers assessed eligibility, extracted data, calculated FIs, and evaluated risk of bias. Frequency-weighted means were used for narrative synthesis.

Results

Eleven RCTs with 4506 patients (mean cohort size: 409.64 ± 160.54) and a mean age of 36.97 ± 13.51 years (n = 4356; 96.67%) were included, covering 24 binary outcomes. The median FI across all outcomes was 3 (interquartile range 1-4; mean 3.92), indicating that changing the outcome of just a few patients could shift a study's results from statistically significant to nonsignificant. Trials having an FI ≤3 comprised 58.33%. Three outcomes (12.5%) had an FI of zero after recalculating P values using the two-sided Fisher exact test. Half of the outcomes were robust. No RCT reported FIs or adjusted significance for multiple testing. Most studies (81.82%) performed 2 or more statistical tests, with an average of 30.81 ± 41.28 P values reported per study. The overall risk of bias was low in 1 study (9.09%) and moderate in 7 (63.64%). Most studies had low risk of bias in randomization (72.73%) and missing outcome data (90.91%).

Conclusion

The FI assesses the fragility of statistically significant binary results, revealing that many ATP RCTs have fragile outcomes due to small sample sizes. A median FI of 3 means that changing the outcome of 3 patients could shift a study's results from statistically significant to nonsignificant.

Audit of a Revised Pathway Aimed at Expediting Diagnosis and Treatment for Suspected Achilles Tendon Rupture

Treatment outcomes for Achilles tendon ruptures depend upon prompt diagnosis and management. A local study in 2018 highlighted inefficiencies in patient management, and a revised protocol was introduced allowing investigation and referral to be initiated by other healthcare professionals. This retrospective audit evaluates the impact of this on the timescale from presentation to treatment. It analyzes all suspected Achilles tendon ruptures within one District General Hospital from April 2021 to March 2022. Data regarding patient timelines was compared to the 2018 study. Over 12 months, 99 patients were referred to Virtual Fracture Clinic, 87.8% (n = 87) of which had a complete or partial tear on ultrasound scan (USS). In comparison to 2018, the average time from presentation to USS request reduced from 2.9 to 1.1 days (p < .01). 95% were scanned within one week of USS request and 31.3% within 48 hours (81% and 18%, previously). The average time from USS request to scan went from 6.8 to 3.2 days (p < .01). The time from presentation to treatment decision reduced from 10.9 to 6.2 days (p < .01) and the percentage of patients with a definitive treatment plan within one week increased from 34.5% to 74.2% (p < .01). Patients required 0.8 fewer appointments (p < .01) giving an estimated total saving of $10,110 ($128 per patient) during the analyzed period. The Achilles Tendon Rupture Pathway has significantly improved the proportion of patients undergoing USS within 48 hours and receiving a treatment decision within one week. This study demonstrates an efficient, cost-saving and replicable pathway for Achilles tendon ruptures.

Dexamethasone treatment influences tendon healing through altered resolution and a direct effect on tendon cells

Inflammation, corticosteroids, and loading all affect tendon healing, with an interaction between them. However, underlying mechanisms behind the effect of corticosteroids and the interaction with loading remain unclear. The aim of this study was to investigate the role of dexamethasone during tendon healing, including specific effects on tendon cells. Rats (n = 36) were randomized to heavy loading or mild loading, the Achilles tendon was transected, and animals were treated with dexamethasone or saline. Gene and protein analyses of the healing tendon were performed for extracellular matrix-, inflammation-, and tendon cell markers. We further tested specific effects of dexamethasone on tendon cells in vitro. Dexamethasone increased mRNA levels of S100A4 and decreased levels of ACTA2/α-SMA, irrespective of load level. Heavy loading + dexamethasone reduced mRNA levels of FN1 and TenC (p < 0.05), while resolution-related genes were unaltered (p > 0.05). In contrast, mild loading + dexamethasone increased mRNA levels of resolution-related genes ANXA1, MRC1, PDPN, and PTGES (p < 0.03). Altered protein levels were confirmed in tendons with mild loading. Dexamethasone treatment in vitro prevented tendon construct formation, increased mRNA levels of S100A4 and decreased levels of SCX and collagens. Dexamethasone during tendon healing appears to act through immunomodulation by promoting resolution, but also through an effect on tendon cells.

Construct validation of a novel synthetic tendon model used for assessing surgeon performance in a simulated core suture tendon repair technique

BACKGROUND

The strength of tendon repair is dependent on the quality of the core suture. Organic and synthetic materials have been used to simulate tendon repair for training; however, no model has undergone construct validation.

OBJECTIVES

To determine the construct validity of a novel synthetic tendon repair model.

METHODS

Synthetic silicone tendon models were used to simulate adult Achilles tendon (AT) and digital flexor tendon (FT). Participants were categorised into novice, intermediate, and advanced groups based on prior surgical experience. Participants repaired tendons using the modified Kessler technique. A validated motion analysis system was used to measure the duration, path length, and movement count during the simulated task. A global rating score was also used to assess the performance.

RESULTS

All participants in the novice (n = 12), intermediate (n = 8) and advanced (n = 11) groups completed the tasks. The results (mean±standard deviation) were duration (872 ± 335, 492 ± 257 and 357 ± 40 s), path length (9493 ± 3173, 6668 ± 1740 and 4672 ± 1228 cm), movement count (4974 ± 673, 4228 ± 259 and 3962 ± 69) and global rating (39 ± 13, 61 ± 14, 81 ± 5), respectively. The Kruskal-Wallis test was significant for all outcome measures (p < 0.01). Significant differences in duration and movement count were identified post-hoc in the AT model for each experience group (p < 0.05), and between novice and intermediate participants for FT repair (p < 0.04). Global rating was significantly different between all groups and was highly correlated with motion metrics (p < 0.01).

CONCLUSION

The results support construct validity of this novel simulated tendon repair model. The global rating scores may allow wide utility of this simulation. This model provides a valid and safe environment for surgical trainees to practice tendon repair with several cost, ethical and logistical benefits over animal tendon use. 248/250.

Recurrent Achilles Tendon Rupture in Multiple Sites as a Primary Manifestation of Systemic Lupus Erythematosus in a 32-Year-Old Patient: A Case Report

The Achilles tendon is vital for walking and running, but it's also the most frequently ruptured tendon. Ruptures often occur without direct trauma and present with acute posterior ankle/heel pain. Various factors like age, biomechanical properties, degeneration, and mechanical factors influence susceptibility to rupture. Mechanisms of injury vary, including weight-bearing forefoot pushing off and sudden dorsiflexion of the ankle. Management goals focus on minimizing morbidity, swift recovery, and preventing complications through tailored interventions. Systemic lupus erythematosus (SLE) can also contribute to tendon rupture, especially with prolonged corticosteroid use. A 32-year-old female presented to the ER after injuring her left foot during a basketball game. She was diagnosed with an Achilles tendon rupture and underwent surgery to repair it. However, she experienced delayed wound closure and needed a skin graft. Two months later, she suffered another rupture in a different location, requiring a tendon transfer surgery. She was finally diagnosed with SLE after tests by the Rheumatology Department. Treatment commenced, and she began rehabilitation four weeks post-surgery. Surgical management of ruptured Achilles tendon involves techniques like open repair, percutaneous repair, mini-open repair, and augmentative repair. Open repair involves a direct approach with a posteromedial incision to align tendon stumps using various stitching techniques. Conservative treatment involves immobilization and non-weight-bearing for at least four weeks post surgery. For rare cases of Achilles tendon rupture caused by lupus, treatment focuses on managing the underlying disease with medications like hydroxychloroquine and glucocorticosteroids. Comprehensive evaluation, including musculoskeletal assessment, is crucial for lupus patients. SLE needs to be considered as a potential cause, especially in cases of recurrent ruptures or additional musculoskeletal symptoms. Surgical management should be tailored to individual patient needs, while also considering surgeon proficiency and preferences.

An in-depth study on the magnetic resonance imaging characteristics of tendon rupture in sports injuries and its correlation with patients' clinical symptoms

Muscle injuries, such as Achilles and quadriceps tendon ruptures, pose a significant challenge in elite sports, accounting for more than 30% of all sports-related injuries. Our primary goal is to investigate the MR imaging characteristics of tendon rupture in sports injuries and their relationship with patients' clinical symptoms. In our retrospective study at Zhejiang University of Traditional Chinese Medicine's Second Affiliated Hospital (Zhejiang Xinhua Hospital), we compared the clinical presentation and MRI results of 106 patients with isolated AT and QT ruptures. In the AT, the enthesis was identified as a common site of bony avulsions (30.2%). In contrast, insertional ruptures were more common in the gastrocnemius heads (69.8% and 66.0%). The low frequency of mid-substance tears (13.2% to 20.8%) demonstrated the central tendon region's inherent tensile strength. The ruptured musculotendinous junctions affected the soleus (20.8%). In QT, bony avulsions play a minor role (5.1% to 11.3%). The patella was the primary site of tears (42.2% - 45.3%), with the Vastus intermedius favoring proximal tears (58.5%). Our examination of AT and QT ruptures across sub-components sheds light on their distinct patterns and the implications for clinical practice in terms of precise diagnosis, personalized treatment, and, ultimately, better patient outcomes for these debilitating injuries.

Modified gastro-soleus turn-down flap for chronic or neglected achilles tendon ruptures

BACKGROUND

Achilles' tendon chronic rupture is a common entity that is usually misdiagnosed or mistreated. Hence, she was presented to us later or with complications affecting her gait. Surgical resection is needed to either bridge the gap or reinforce the strength of the tendon repair.

OBJECTIVES

Our study's goal was to assess the clinical results of repairing chronic Achilles' tendon lesions employing the middle segment of the proximal portion of the tendon (gastro-soleus), as a turn-down flap.

METHODS

Our prospective interventional single arm study included 18 patients with chronic Achilles' tendon rupture attending at Al-Azhar university hospitals in Cairo, Egypt from May 2020 to April 2023. Diagnosis of the patients was confirmed by radiographic and clinical investigations. They were all treated with the same open reconstruction procedure using a modified GSF. The average follow-up was 12 months. The results of this study were assessed by the Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) score, and capacity to perform repeated heel raises on the affected side.

RESULTS

The mean operative time was 72.77 min. The median (IQR) time of reconstruction was 10 (8-12) after the injury. The median (IQR) length of flab was 4.5 (4.3-5) 9 (Table 2). No intraoperative complications occurred. The typical follow-up period was 12 months (6-18 months). In terms of the ATRS, we found a significant reduction from 82.8 ± 3 preoperatively to 20.8 ± 6.7 at 12 months postoperatively (P value = 0.001). As regards the AOFAS score, it was increased from 49.5 ± 10 preoperatively to 83.8 ± 8.5 12 months postoperatively (P = 0.001). In terms of the post operative complications, there was no re-rupture. Two patients experienced superficial wound infection which improved with daily dressing and antibiotics. Additionally, two patients had slight ankle stiffness four months after the operation, which improved after programmed rehabilitation at the sixth month.

CONCLUSION

The modified GSTF is a simple, safe, well-tolerated and effective method of treatment with excellent functional results and greater patient content.

The Significance of Proprioceptive Training in the Post-Operative Rehabilitation of Patients Undergoing Achilles Tendon Reconstruction

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.

Dynamic Tensile Stress Promotes Regeneration of Achilles Tendon in a Panda Rope Bridge Technique Mice Model

Regeneration of ruptured Achilles tendon remains a clinical challenge owing to its limited regenerative capacity. Dynamic tensile stress plays a positive role in the regeneration of tendon, although the specific underlying mechanisms remain unclear. In this study, the Achilles tendon defect-regeneration model was created in male C57BL/6 mice aged 8 weeks. The animals were randomly assigned to four groups-repair, non-repair, repair with fixation, and non-repair with fixation. The repair group and repair with fixation group adopted the panda rope bridge technique (PRBT) repair method. Our results demonstrated the presence of more densely aligned and mature collagen fibers, as well as more tendon-related makers, in the repair group at both 2- and 4-week post-surgery. Furthermore, the biomechanical strength of the regenerated tendon in the repair group was highly improved. Most importantly, the expressions of integrin αv and its downstream and the phosphorylation levels of FAK and ERK were remarkably higher in the repair group than in the other groups. Furthermore, blocking FAK or ERK with selective inhibitors PF573228 and U0126 resulted in obvious adverse effects on the histological structure of the regenerated Achilles tendon. In summary, this study demonstrated that dynamic tensile stress based on the PRBT could effectively promote the regeneration of the Achilles tendon, suggesting that dynamic tensile stress enhances the cell proliferation and tenogenic differentiation via the activation of the integrin/FAK/ERK signaling pathway.

A Segmental Rupture of Achilles Tendon, its Management, and Outcome - A Rare Case Report

Introduction

Achilles tendon is the thickest and strongest tendon of the body, spanning from the middle of the calf up to its insertion into the calcaneal tuberosity, and it is estimated to be the third most frequent tendon to rupture. Segmental Achilles tendon rupture, however, is a very rare occurrence and it comes with challenges of salvaging the tendon segment, preventing necrosis of the overlying skin, preventing infection, and preserving the repaired construct to regain good functional outcome. We present a rare case of an acute traumatic segmental rupture of Achilles tendon in a young male, its management and outcome.

Case Report

A 25-year-old male suffered a direct blow to the posterior aspect of his left ankle above the heel and presented to us on the same day. On examination, a lacerated wound with visible ruptured ends of the tendon was found. A palpable gap was also felt over a proximal sutured wound and a real-time ultrasonography revealed a complete tear of Achilles tendon in the proximal site as well. Both the wounds were explored and a segmental Achilles tendon rupture was found. A dual level Krackow's suturing was done with augmentation of the distal repair with anchorage in the calcaneus. Following a stringent post-operative rehabilitation, the patient was allowed weight-bearing from 12 weeks onward. At 6-month follow-up, the tendon continuity was intact both clinically and radiologically, and the patient was able to ambulate bearing full weight having bilaterally comparable ankle range of motion.

Conclusion

Rupture of Achilles tendon is relatively common; however, a segmental rupture of the tendon is very rare and poses a challenge for optimum management. Awareness about the possible complications and addressing them with a timely intervention followed by a well-balanced rehabilitation can salvage the tendon and yield good results.

Flexor Hallucis Longus Transfer And V-Y Plasty: An Effective Treatment Modality for Chronic Achilles Rupture - A Case Series

Introduction

To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy.

Materials and methods

A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y plasty for Achilles tendon rupture. Patients were allowed full weight bearing at six weeks post-operatively, and were followed up at three months and six months post-operatively, when the range of motion of the ankle was examined, and the outcome was assessed using the EFAS score.

Results

Of the 12 patients in the study, the majority were males; the mean age was 50.6±8.96 years. A significant improvement in dorsiflexion and plantarflexion was noted at the six-month follow-up compared to the three-month follow-up (P=<0.001 for both). When compared to the normal side, dorsiflexion and plantarflexion of the affected ankle were significantly less at three months but were comparable at six months post-operatively. A significant improvement was noted in the mean EFAS score at the six-month follow-up (25.5±5.71) compared to three months (18.6±0.90) post-surgery (P=0.001). Males were also noted to have significantly higher EFAS scores at their six-month follow-up than females (P=0.022). In contrast, a negative correlation was noted between the European Foot and Ankle Society (EFAS) score at the final follow-up and age (P=0.011).

Conclusion

FHL tendon transfer with V-Y plasty in chronic Achilles rupture due to insertional Achilles tendinopathy is an effective procedure resulting in the restoration of the ankle range of motion and improvement in functional scores.

Absorbable vs Nonabsorbable Sutures for Achilles Tendon Repair: A Systematic Review and Meta-analysis

Background

Nonabsorbable sutures are still the main choice for acute Achilles tendon rupture (AATR) repair due to strength provided. However, the rerupture rates, infection risks, foreign body reaction, and postsurgical recovery differences between absorbable and nonabsorbable suture materials in AATR repair have not been carefully reviewed.

Methods

A systematic review was done on PubMed, EBSCO, Cochrane Central Register of Controlled Trials, and Embase to find research studies in relation to complications associated with AATR repair using the PRISMA guidelines. The risk of bias from each study included will be assessed using the Cochrane Risk of Bias Tool for randomized study (RoB 2) and Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) for nonrandomized study.

Results

Five studies with a total of 255 patients, 105 in the absorbable suture group and 150 in the nonabsorbable suture group, were included for analysis. Risk of rerupture, infection, and foreign body reaction shown no significant difference between groups, and the mean difference of recovery scores were similar.

Conclusion

Existing literature shows that absorbable sutures appear to be associated with similar outcomes to nonabsorbable sutures regarding rates of rerupture, infection, foreign body reaction, and outcomes grading following surgical repair of acute Achilles tendon repair.

Return to Play Following Achilles Tendon Rupture in NFL Players Based on Position

BACKGROUND

The purpose of this study was to determine the return-to-play (RTP) rate and postinjury performance after Achilles tendon (AT) ruptures in National Football League (NFL) skill position players.

METHODS

The study included NFL skill positions with an AT rupture between the 2009-2010 and 2015-2016 seasons. Performance data were collected and compared against a matched control group. RTP was defined as playing in at least 1 game after repair.

RESULTS

RTP rate was 57% for the study cohort. The tight ends (TEs) had the highest RTP rate at 71% while the wide receivers (WRs) had the lowest RTP rate at 38%. Compared with the control group, WRs with successful RTP had significantly less receptions per game (P = .01). For defensive players with RTP there were significant decreases in postrepair performance in tackles, passes defended, and fumbles forced/recovered compared with the control group.

CONCLUSION

A total of 57% of players achieved RTP with WRs and running backs (RBs) having the lowest RTP rates and TEs and linebackers (LBs) having the highest RTP rates. RBs, defensive backs (DBs), and LBs with successful RTP had decreased performance in all categories. This updated information may be helpful for athletes, physicians, scouts, and coaches in evaluating players with a history of AT rupture.

LEVELS OF EVIDENCE

Analytic, level 3, retrospective cohort study, Epidemiologic study.

A clinical comparison of two different surgical techniques in the treatment of acute Achilles tendon ruptures: Limited-open approach vs. percutaneous approach

BACKGROUND

Surgical treatment is the commonly preferred method for treating acute Achilles tendon ruptures (AATRs) due to advantages such as less re-rupture rates, better functional results, and an early return to physical activities. The main aim of our study is to compare two common minimally invasive surgical methods, the limited open and the percutaneous approaches, regarding clinical outcomes.

METHODS

A total of 53 patients (19 females and 34 males) who were treated with limited open (Group 1: 30 patients) and percutaneous (Group 2: 23 patients) approaches for AATRs were retrospectively evaluated between March 2019 and May 2020 in a level 1 trauma center. The evaluation included complications (soft tissue and skin problems, re-rupture, and sural nerve injury rates), the operation time, the duration of return to daily activities, The Achilles Tendon Total Rupture Score (ATRS), and the American Ortho-pedic Foot and Ankle Society (AOFAS) scores of the patients at the first and 6th months of follow-up. Patients' activity levels were compared with the Tegner Activity Scale (TAS).

RESULTS

The mean age of all patients in this cohort was 45.1±14.1. The mean postoperative follow-up period for group 1 was 36.9±8.81 weeks, whereas, for group 2, it was 35.4±8.73 weeks (P=0.24). The mean age (P=0.47), gender distribution (P=0.41), and body mass index (P=0.29) were similar for both groups. The mean operation time (group 1: 47.1±5.4 vs. group 2: 44.4±6.1, P=0.06) and the duration of return to daily activities (group 1: 49.2±7.4 vs. group 2: 48.5±9.7, P=0.38) were also similar. There was no statistical difference between groups regarding functional results at first (ATRS: group 1: 79.9±3.2 vs. group 2: 79.5±3.9, [P=0.35], and AOFAS: group 1: 80.9±3.1 vs. group 2: 82.1±3.2, [P=0.10]) and 6th months (ATRS: group 1: 85.0±3.8 vs. group 2: 83.7±4.4, [P=0.13], and AO-FAS: group 1: 86.6±3.6 vs. group 2: 86.7±4.2, [P=0.46]). There were no statistically significant differences between groups regarding preoperative and last follow-up TAS scores (P= 0.94 and P=0.46, respectively). We observed no postoperative complications in group 1. There were three complications (13.1%) in group 2. One patient (4.4%) had a re-rupture, and two patients (8.7%) had sural nerve injuries.

CONCLUSION

Although both groups had similar functional results, the limited open approach yielded better clinical outcomes according to the complication results than the percutaneous approach.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair.

PURPOSE

The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time.

RESULTS

There were 10 RCTs that qualified for the meta-analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], -0.73 [95% CI, -1.70 to 0.25]; P = .14; I² = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I² = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I² = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I² = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I² = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I² = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I² = 15%).

CONCLUSION

Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

Percutaneous achilles tendon repair with absorbable suture: Outcomes and complications

OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

A prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted.

INCLUSION CRITERIA

≥18 years of age, non-insertional (2-8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected. Patients were assessed using visual analogue scale (VAS) at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score (ATRS) were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected.

CONCLUSIONS

In our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

The Efficacy of Posterior Fasciotomy Versus Inserted Vacuum Drainage in Reducing Postoperative Surgical Site Infection in Open Achilles Tendon Repair: A Prospective Cohort Study With Inverse Probability Treatment Weight Propensity Score Analysis

Posterior crural fasciotomy (PF) may reduce postoperative surgical site infection (SSI) rate compared to inserted vacuum suction drainage (VD) in open Achilles tendon repair surgery. Thus, we aimed to compare the postoperative SSI rate between PF and VD in open Achilles's tendon repair surgery. A prospective, single-centered, nonrandomized controlled study of consecutive adult patients undergoing primary open Achilles tendon repair was performed at tertiary referral hospital between January 2017 and January 2020. Patients received either PF or VD from 2 experienced surgeons. Data were collected on demographic, clinical, and intraoperative characteristics along with postoperative SSI and other outcomes. The primary outcome was SSI rate. Secondary outcomes were Achilles tendon total rupture score, functional foot index, and visual analogue scale. A total of 60 patients were eligible and included in the final analysis (PF group n = 30 and VD group n = 30). Two (6.7%) patients in the PF group and 5 (16.7%) patients in the VD group experience postoperative SSI (crude risk ratio 0.40; 95% confidence interval 0.08, 1.90; p = .228). In inverse-probability-treatment-weighted propensity score analysis, the PF group had a significantly lower SSI rate than the VD group (adjusted risk ratio 0.30; 95% confidence interval 0.01, 0.91; p = .033). Inverse-probability-treatment-weighted propensity score analysis of Achilles tendon total rupture score along with crude analysis of total functional foot index and visual analogue scale were also significantly better in the PF group than the VD group (all p < .05). PF during open Achilles repair was associated with a significant reduction in postoperative SSI infection rate compared to VD.

Percutaneous achilles tendon repair with absorbable suture: Outcomes and complications

OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

A prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted.

INCLUSION CRITERIA

≥18 years of age, non-insertional (2-8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected. Patients were assessed using visual analogue scale at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected.

CONCLUSIONS

In our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

Prospective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).

INCLUSION CRITERIA

≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected.

RESULTS

VAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries).

CONCLUSIONS

Percutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

Prospective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).

INCLUSION CRITERIA

≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected.

RESULTS

VAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries).

CONCLUSIONS

Percutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

A New Technique of Achilles Tendon Rupture Repaired by Double Transverse Mini-incision to Avoid Sural Nerve Injury: A Consecutive Retrospective Study

OBJECTIVE

Percutaneous suture is a classic technique used in Achilles tendon repair. However, the complication rates surrounding the sural nerve remain relatively high. Modified percutaneous repair technology can effectively avoid these complications; however, the surgical procedure is complicated. Hence, the present study was conducted to describe a redesigned repair technique for the Achilles tendon able to avoid sural nerve injury and reduce the complexity of the procedure.

METHODS

Data of patients with acute primary Achilles tendon rupture at our hospital from January 2019 to May 2020 were included. Subjects with expectations for surgical scarring underwent a minimally invasive-combined percutaneous puncture technique. The surgical time, requirement for conversion to other technologies, and length of postoperative hospitalization were investigated to assess efficacy. The American Orthopedic Foot & Ankle Society (AOFAS) score and the Arner-Lindholm scale (A-L scale) were used to assess postoperative clinical outcomes (> 24 months). During the 2-year follow-up, MRI was performed to observe the healing of the Achilles tendon. In addition, subjective satisfaction with surgical scar healing was recorded.

RESULTS

Twenty consecutive subjects with an average follow-up of 28.3 ± 4.5 months (range, 24-41) met the inclusion criteria. None of the 20 enrolled patients required a converted surgical approach. The mean surgical time was 26.9 ± 6.47 min (range, 20-44). None of the patients experienced dysesthesia or anesthesia around the sural nerve. No signs of postoperative infections were observed. MRI data showed that the wounds of the Achilles tendon healed completely in all the subjects. The AOFAS score increased from 55.6 ± 11.07 (range, 28-71) preoperatively to 97.8 ± 3.34 (range, 87-100) at the last follow-up. The A-L scale showed that 90% of the subjects (n = 18) presented as excellent and 10% of the subjects (n = 2) presented as good, with an excellent/good rate of 100%. Moreover, subjects' satisfaction for surgical scars was 9.1 ± 0.78 (upper limit, 10).

CONCLUSIONS

The results indicate that this technique can achieve good postoperative function, a small surgical incision, and high scar satisfaction. In addition, this technique should be widely used in suturing Achilles tendon ruptures.

Minimally Invasive Mid-Substance Achilles Tendon Repair Using the Percutaneous Achilles Repair System (PARS)

Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities^1,2. Many patients want to continue participating in recreational activities, which can be facilitated by operatively treating the injury in a timely fashion, maximizing their functional recovery. The Percutaneous Achilles Repair System (PARS) Jig (Arthrex) can be utilized in patients with acute mid-substance Achilles tendon ruptures^3,4.

Description

Begin by positioning the patient prone with a thigh tourniquet on the operative side. Mark a 3-cm transverse incision 1 cm distal to the proximal Achilles stump and make the incision, taking care to protect the sural nerve laterally. Next, create a transverse paratenon incision and bluntly dissect it from the Achilles circumferentially. After gaining access to the proximal Achilles stump, clamp it with an Allis clamp and insert the PARS Jig between the Achilles tendon and paratenon, sliding it proximally to the myotendinous junction. To secure the jig to the proximal Achilles tendon, insert a guide pin into the jig position-1 hole. To pass sutures through the Achilles tendon, insert pins with their respective sutures into positions 2 through 5 and insert the FiberTape suture (Arthrex) in position 1. Remove the jig from the transverse incision, pulling the suture ends out of the incision. Once they are out, reorient the sutures on the medial and lateral sides to match their positions when initially placed. On both sides, wrap the blue suture around the 2 striped green-and-white sutures twice, and pull the blue suture through the looped green-and-white suture on the ipsilateral side. After doing that, fold the blue suture on itself to create a shuttling suture with the green-and-white suture. Next, pull on the medial non-looped green-and-white suture until it has been pulled out medially, and repeat that with the lateral non-looped green-and-white suture until it has been pulled out laterally, to create a locking stitch. Group the medial sutures together and the lateral sutures together, and utilize a free needle to further incorporate both bundles of sutures into the Achilles tendon. Next, create bilateral mini-incisions 1.5 cm proximal to the calcaneal tuberosity. Insert a rigid cannulated suture-passing device into each mini-incision, pass it through the distal Achilles tendon, load the ipsilateral suture bundle into the Nitinol wire, and pull the suture-passing device out the distal mini-incision to approximate the Achilles. To prepare the calcaneus, drill calcaneal tunnels toward the midline bilaterally, taking care to avoid convergence of the tunnels. Place a suture-passing needle in the tunnels to assist with placing the anchors. Next, tension the sutures, cycling them 5 to 10 times to remove any slack in the system. With the ankle in 15° of plantar flexion, anchor the sutures with cortical bioabsorbable interference screws, following the angle that the suture-passing needles are in. After confirming function of the Achilles tendon, close the peritenon, deep tissues, and superficial tissues, and place the ankle in a splint in 15° of plantar flexion.

Alternatives

Acute Achilles ruptures can be treated operatively or nonoperatively^1,2. Operative techniques include open, percutaneous, or minimally invasive Achilles tendon repair. Open Achilles tendon repair involves making a 10-cm posteromedial incision to perform a primary repair⁵, while percutaneous Achilles tendon repair involves the use of medial and lateral mini-incisions to pass needles and sutures into the Achilles tendon to repair it⁶. Minimally invasive Achilles tendon repair involves the use of a small 3 to 4-cm incision to introduce instrumentation such as modified ring forceps or an Achillon device (Integra)^7,8, along with a percutaneous technique, to repair the Achilles tendon. Nonoperative treatment can be utilized in patients with <5 mm of gapping between the ruptured tendon edges on dynamic ultrasound in 30° of plantar flexion⁹, in patients with limited activity, or in patients whose comorbidities make them high-risk surgical candidates. Nonoperative treatment includes a below-the-knee rigid cast in 30° of plantar flexion or the use of a functional splint in 30° of plantar flexion with gradual progression to a neutral position, along with early rehabilitation according to the postoperative protocol described in the present article.

Rationale

This technique allows patients to begin early postoperative rehabilitation, limits wound and soft-tissue complications such as superficial and deep infections, and protects neurovascular structures such as the sural nerve that may be injured if utilizing other techniques. These benefits are achieved through the use of a minimally invasive knotless approach that places nearly all of the suture material into the Achilles tendon, reducing friction within the paratenon and potentially facilitating improved gliding. Additionally, securing the sutures into the calcaneus minimizes postoperative Achilles tendon elongation and facilitates early postoperative rehabilitation.

Expected Outcomes

Patients undergoing this procedure can expect to return to their baseline physical activities by 5 months³, with the best functional results observed at ≥12 months postoperatively⁴. One retrospective cohort study compared the results of 101 patients who underwent Achilles repair with use of the PARS Jig and 169 patients who underwent open Achilles repair, and found that 98% of PARS patients returned to baseline activities in 5 months compared with 82% of patients undergoing open Achilles repair (p = 0.0001)³. Another retrospective chart review assessed the results of 19 patients who underwent Achilles repair with the PARS Jig⁴ and found that patients began to return to sport as early as 3 months postoperatively and that functional scores in patients increased as time progressed, with significant increases observed at 12 months and longer postoperatively.

Important Tips

Locate the Achilles tendon rupture site prior to marking the transverse incision.Bluntly dissecting the paratenon during closure stimulates healing and reduces scarring, thereby maintaining the integrity of the tissue¹⁰.When advancing the PARS Jig, ensure that the proximal Achilles tendon remains inside the device.Maintaining meticulous suture management and organization prevents tangles and improves suture shuttling.Ensure that the Achilles tendon is tensioned with the ankle in 15° of plantar flexion prior to distal anchor fixation.

Acronyms and Abbreviations

MRI = magnetic resonance imagingUS = ultrasoundBID = twice dailyPRN = as neededDVT = deep vein thrombosis.

Outcomes of Percutaneous Achilles Repair Compared With Endoscopic Flexor Hallucis Longus Tendon Transfer to Treat Achilles Tendon Ruptures

BACKGROUND

Both percutaneous and endoscopically assisted methods are reported to produce good results in the surgical management of acute Achilles tendon ruptures. The aim of this retrospective study was to compare between a percutaneous method and a recently described isolated endoscopically assisted flexor hallucis longus (FHL) transfer method as surgical means of management in patients with acute Achilles tendon ruptures.

METHODS

One hundred seventeen patients were included in the current study and divided into 2 groups: 59 patients who underwent percutaneous Achilles repair (PAR Group) and 58 patients who underwent isolated endoscopic FHL transfer (FHL Group) were compared. Patients were clinically evaluated using American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score (ATRS), and Achilles tendon resting angle (ATRA) measures. In addition, ankle plantarflexion power, FHL dynamometry, Tegner activity levels, and return to previous levels of activity were also documented for all patients.

RESULTS

Nine months after surgery, patients in the FHL transfer group were more likely to be able to return to normal activities (91% vs 73%, P < .01). Thirty months after surgical treatment, we found no difference in ATRS, AOFAS, ATRA, ankle plantarflexion strength, or Tegner activity scores between study groups. Overall complications were reported in 6 patients in the FHL group (10.3%) and in 8 patients in the PAR group (13.6%). No major neurovascular or skin complications were encountered.

CONCLUSION

The current study demonstrated satisfactory and comparable results and complications when comparing isolated endoscopic FHL tendon transfer or percutaneous Achilles tendon repairs in the surgical management of acute Achilles tendon ruptures.

LEVEL OF EVIDENCE

Level III, retrospective controlled trial.

Absorbable versus nonabsorbable sutures for the Krackow suture repair of acute Achilles tendon rupture: a prospective randomized controlled trial

AIMS

Although absorbable sutures for the repair of acute Achilles tendon rupture (ATR) have been attracting attention, the rationale for their use remains insufficient. This study prospectively compared the outcomes of absorbable and nonabsorbable sutures for the repair of acute ATR.

METHODS

A total of 40 patients were randomly assigned to either braided absorbable polyglactin suture or braided nonabsorbable polyethylene terephthalate suture groups. ATR was then repaired using the Krackow suture method. At three and six months after surgery, the isokinetic muscle strength of ankle plantar flexion was measured using a computer-based Cybex dynamometer. At six and 12 months after surgery, patient-reported outcomes were measured using the Achilles tendon Total Rupture Score (ATRS), visual analogue scale for pain (VAS pain), and EuroQoL five-dimension health questionnaire (EQ-5D).

RESULTS

Overall, 37 patients completed 12 months of follow-up. No difference was observed between the two groups in terms of isokinetic plantar flexion strength, ATRS, VAS pain, or EQ-5D. No re-rupture was observed in either group.

CONCLUSION

The use of absorbable sutures for the repair of acute ATR was not inferior to that of nonabsorbable sutures. This finding suggests that absorbable sutures can be considered for the repair of acute ATRs. Cite this article: Bone Joint J 2022;104-B(8):938-945.

Operative versus conservative treatment of acute Achilles tendon ruptures: preliminary results of clinical outcome, kinematic MRI and contrast-enhanced ultrasound

INTRODUCTION

There is no uniform consensus on the gold standard therapy for acute Achilles tendon rupture. The aim of this pilot study was to compare operative and conservative treatment regarding imaging findings and clinical outcome.

MATERIALS AND METHODS

Surgically or conservatively treated patients with acute Achilles tendon rupture were retrospectively evaluated. Differences in tendon length and diameter with and without load were analysed using kinematic MRI, tendon perfusion, structural alterations, movement and scar tissue by means of grey-scale and contrast-enhanced ultrasound (CEUS). Intra- and interobserver agreement were recorded.

RESULTS

No significant difference was detected regarding clinical outcome, B mode ultrasonography, contrast-enhanced sonography or MRI findings, although alterations in MRI-based measurements of tendon elasticity were found for both groups. Considerable elongation and thickening of the injured tendon were detected in both groups.

CONCLUSION

Both, conservative and surgical treatment showed comparable outcomes in our preliminary results and may suggest non-inferiority of a conservative approach.

Long-term anti-inflammatory effects of injectable celecoxib nanoparticle hydrogels for Achilles tendon regeneration

The treatment of chronic Achilles tendonitis (AT) often requires prolonged therapy and invasive therapeutic methods such as surgery or therapeutic endoscopy. To prevent the progression of chronic AT, excessive inflammation must be alleviated at an early stage. Corticosteroids or nonsteroidal anti-inflammatory drugs are generally prescribed to control inflammation; however, the high doses and long therapeutic periods required may lead to serious side effects. Herein, a local injectable poly(organophosphazene) (PPZ) - celecoxib (CXB) nanoparticle (PCNP) hydrogel system with long-term anti-inflammatory effects was developed for the treatment of tendonitis. The amphiphilic structure and thermosensitive mechanical properties of PPZ means that the hydrophobic CXB can be easily incorporated into the hydrophobic core to form PCNP at 4 °C. Following the injection of PCNP into the AT, PCNP hydrogel formed at body temperature and induced long-term local anti-inflammatory effects via sustained release of the PCNP. The therapeutic effects of the injectable PCNP system can alleviate excessive inflammation during the early stages of tissue damage and boost tissue regeneration. This study suggests that PCNP has significant potential as a long-term anti-inflammatory agent through sustained nonsteroidal anti-inflammatory drugs (NSAIDs) delivery and tissue regeneration boosting. STATEMENT OF SIGNIFICANCE: In the treatment of Achilles tendinitis, a long-term anti-inflammatory effect is needed to alleviate excessive inflammation and induce regeneration of the damaged Achilles tendon. Injectable poly(organophosphazene)(PPZ)-celecoxib(CXB) nanoparticles (PCNP) generated a long-term, localized-anti-inflammatory effect in the injected region, which successfully induced the expression of anti-inflammatory cytokines and suppressed pro-inflammatory cytokines, while the PCNPs degraded completely. Accordingly, regeneration of the damaged Achilles tendon was achieved through the long-term anti-inflammatory effect induced by a single PCNP injection. The PCNP system therefore has great potential in long-term NSAIDs delivery for various tissue engineering applications.

Rates of complications in Achilles tendon rupture repair using absorbable and nonabsorbable suture material; A systematic review

BACKGROUND

The impact of suture type on tensile strength, re-rupture rates and infection risk in Achilles tendon rupture repair is not been well established. The aim of this review is to evaluate existing literature on the associated risk of postoperative infection with absorbable and non-absorbable suture materials in Achilles tendon rupture repair.

METHODS

A systematic review of search databases PubMed; Google Scholar; and OVID Medline was made to identify studies related to complications associated with Achilles tendon rupture repair. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare rupture rates and infections following rupture repair.

RESULTS

12 studies with a total of 460 patients, 230 in both nonabsorbable and absorbable suture groups were included for analysis. Risk of wound complications was significantly higher in patients with non-absorbable sutures (p < 0.001).

CONCLUSION

Nonabsorbable braided sutures is associated with the highest risk of postoperative wound complications following Achilles tendon rupture repair.

Achilles Injury and Access to Care in South Florida

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Gene electrotransfer of FGF2 enhances collagen scaffold biocompatibility

Tendon injuries are a common athletic injury that have been increasing in prevalence. While there are current clinical treatments for tendon injuries, they have relatively long recovery times and often do not restore native function of the tendon. In the current study, gene electrotransfer (GET) parameters for delivery to the skin were optimized with monophasic and biphasic pulses with reporter and effector genes towards optimizing underlying tendon healing. Tissue twitching and damage, as well as gene expression and distribution were evaluated. Bioprinted collagen scaffolds, mimicking healthy tendon structure were then implanted subcutaneously for biocompatibility and angiogenesis analyses when combined with GET to accelerate healing. GET of human fibroblast FGF2 significantly increased angiogenesis and biocompatibility of the bioprinted implants when compared to implant only sites. The combination of bioprinted collagen fibers and angiogenic GET therapy may lead to better graft biocompatibility in tendon repair.

Insertional versus non-insertional tendoachilles tears: a comparative analysis of various predisposing factors and outcome following a repair

BACKGROUND

Association of tendon degeneration, pre-existing posterior heel pain, Haglund's bump, retrocalcaneal spur, and mode of injury varies for the insertional and non-insertional type of tendoachilles tears (TA).

PURPOSE

The study compares the various predisposing factors that determine the distinct type of TA tear and the outcome following a repair.

METHODS

This is a retrospective study of the patients who underwent tendoachilles repair during January 2012-June 2018. Patients above 18 years with a minimum follow-up of two years were included. Patients with calcaneal tuberosity avulsions, prior surgeries, and open injuries were excluded. Patients were divided into groups 1 (insertional tears (IT)) and 2 (non-insertional tears (NIT)), and further subdivided based on the tendon degeneration (as D-degenerative and N-normal sub types) from ultrasound findings. AOFAS score and predisposing factors like degeneration, posterior heel pain, Haglund's bump, spur, and mechanism of injury were compared between the groups.

RESULTS

The study included N = 146 with a mean age of 51.6 years and mean follow-up of 38.6 (range 24 to 96) months. IT associated with degeneration (IT-D) had a trivial fall as the predominant mechanism (P < 0.001). All patients had significant postoperative improvement of scores with no significant difference between the groups (P = 0.59) and subgroups (P = 0.27).75.34% had degenerative tendon, of which 64.5% were in the IT group and the rest in the NIT group (P = 0.02). 51.4% patients had a Haglund bump in the IT group and n.s. (P = 0.9). Forty-seven percent of patients had pre-existing posterior heel pain, 68% in IT and 32% in NIT (P = 0.04). Subgroup analysis revealed 65% of patients were in the IT-D subgroup (P < 0.001).

CONCLUSION

Predisposing factors like posterior heel pain, tendon degeneration, and trivial trauma have a strong propensity for insertional TA tear. In contrast, the prominence of Haglund's bump does not predispose to a distinct type of TA tears. The outcome following a surgical repair-yields good results with no difference between the two groups.

Ground Reaction Forces during Vertical Hops Are Correlated with the Number of Supervised Physiotherapy Visits after Achilles Tendon Surgery

The objective of this study was to assess the effectiveness of, and the correlation between, an average of 42 supervised physiotherapy (SVPh) visits for the vertical ground reaction forces component (vGRF) using ankle hops during two- and one-legged vertical hops (TLH and OLH, respectively), six months after the surgical suturing of the Achilles tendon using the open method (SSATOM) via Keesler’s technique. Hypothesis: Six months of supervised physiotherapy with a higher number of visits (SPHNVs) was positively correlated with higher vGRF values during TLH and OLH. Group I comprised male patients (n = 23) after SSATOM (SVPh x = 42 visits), and Group II comprised males (n = 23) without Achilles tendon injuries. In the study groups, vGRF was measured during TLH and OLH in the landing phase using two force plates. The vGRF was normalized to the body mass. The limb symmetry index (LSI) of vGRF values was calculated. The ranges of motion of the foot and circumferences of the ankle joint and shin were measured. Then, 10 m unassisted walking, the Thompson test, and pain were assessed. A parametric test for dependent and independent samples, ANOVA and Tukey’s test for between-group comparisons, and linear Pearson’s correlation coefficient calculations were performed. Group I revealed significantly lower vGRF values during TLH and OLH for the operated limb and LSI values compared with the right and left legs in Group II (p ≤ 0.001). A larger number of visits correlates with higher vGRF values for the operated limb during TLH (r = 0.503; p = 0.014) and OLH (r = 0.505; p = 0.014). An average of 42 SVPh visits in 6 months was insufficient to obtain similar values of relative vGRF and their LSI during TLH and OLH, but the hypothesis was confirmed that SPHNVs correlate with higher relative vGRF values during TLH and OLH in the landing phase.

Long Term Clinical-Functional and Ultrasound Outcomes in Recreational Athletes after Achilles Tendon Rupture: Ma and Griffith versus Tenolig

Background and Objectives: The purpose of this retrospective study was to compare the long-term clinical-functional and ultrasound outcomes of recreational athletes treated with two percutaneous techniques: Ma and Griffith (M&G) and the Tenolig technique (TT). Materials and Methods: recreational athletes, between 18 and 50 years of age, affected by acute Achilles tendon rupture (AATR), treated by M&G or Tenolig techniques were recruited. Clinical-functional outcomes were evaluated using Achilles Tendon Rupture Score (ATRS), AOFAS Ankle-Hindfoot score, VAS (for pain and satisfaction) questionnaires, and ultrasound analysis (focal thickening, hypoechoic areas, presence of calcifications, tendinitis and alteration of normal fibrillar architecture). Results: 90 patients were included: 50 treated by M&G, 40 by TT. In all, 90% of patients resumed sports activities, with pre-injury levels in 56% of cases after M&G and in 60% after TT. In the M&G group, the averages of the questionnaires were ATRS 90.70 points, AOFAS 91.03, VAS satisfaction 7.08, and VAS pain 1.58. In the TT group: ATRS 90.38 points, AOFAS 90.28, VAS satisfaction 7.76, and VAS pain 1.34. The TT group showed a significantly higher satisfaction and return to sport activities within a shorter time. In the M&G group, ultrasound check showed a significantly greater incidence of thickening and an alteration of fibrillar architecture in the treated tendon. Three infections were reported, including one deep after M&G, two superficial in the TT group, and two re-ruptures in the Tenolig group following a further trauma. Conclusions: At long-term follow-up, M&G and TT are both valid techniques for the treatment of AATRs in recreational athletes, achieving comparable clinical-functional results. However, TT seems to have a higher patient satisfaction rate, a faster return to sports and physical activities, and fewer ultrasound signs of tendinitis. Finally, the cost of the device makes this technique more expensive.

Management of chronic Achilles ruptures: a scoping review

PURPOSE

This scoping review aims to systematically map and summarise the available evidence on the management of chronic Achilles ruptures, whilst identifying prognostic factors and areas of future research.

METHODS

A scoping review was performed according to the frameworks of Arksey and O'Malley, Levac and Peters. A computer-based search was performed in PubMed, Embase, EmCare, CINAHL, ISI Web of Science and Scopus, for articles reporting treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to pre-defined selection criteria.

RESULTS

A total of 747 unique articles were identified, of which 73 (9.8%) met all inclusion criteria. A variety of methods are described, with flexor hallucis longus tendon transfer being the most common. The most commonly reported outcome is the American Orthopaedic Foot and Ankle Society (AOFAS) score, although 16 other measures were reported in the literatures. All studies comparing pre- and post-operative outcomes reported significant post-treatment improvement. Complications were reported in 50 studies, with an overall pooled complication rate of 168/1065 (15.8%).

CONCLUSION

Although beneficial results were reported following a variety of techniques, comparison between these is challenging due to the low-level study designs used and confounding factors such as treatment delay and tendon gap size. Further research comparing the efficacy of different techniques is required in order to facilitate the development of an evidence-based treatment protocol. Such work would allow clinicians to better understand the suitability of the large variety of reported techniques and select the optimal strategy for each individual patient.

Augmented Repair of Acute Total Achilles Tendon Rupture With Peroneus Brevis Tendon Transfer Using Oblique Transosseous Calcaneal Tunnel: A Prospective Case Series

Acute Achilles tendon rupture is one of the most common tendon injuries. This prospective study aimed to evaluate the functional outcomes of augmented repair of acute Achilles tendon rupture with peroneus brevis tendon transfer and fixation to an oblique calcaneal transosseous tunnel. Functional evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS). Postoperative complications were recorded. This study included 33 males and 9 females, with a mean age of 26.1 ± 4.2 years. The Achilles tendon ruptures were right in 24 patients and left in 18 patients. The cause of rupture was sports injuries in all patients. The mean distance from the calcaneal insertion to the tear site was 4.4 ± 1.3 cm. The mean time from injury to surgery was 2.4 ± 1.6 days. The mean follow-up time was 40.3 ± 4.9 months. The mean AOFAS and ATRS scores were 99.3 ± 1.2 and 95.9 ± 1.9, respectively, at 12 months of follow-up. The mean time to return to work was 12.1 ± 1.2 weeks. The mean time to return to light sports activities was 16.1 ± 1.8 weeks postoperatively. None of the patients developed re-rupture. Augmented repair of acute Achilles tendon ruptures with peroneus brevis tendon transfer is a robust repair with excellent functional outcomes and early weight-bearing and return to sports activities.

Predisposing Factors for 30-Day Complications Following Achilles Tendon Repair

Certain risk factors for Achilles tendon repair complications, including tobacco use, diabetes mellitus, steroid use, and obesity, have been well-reviewed. This study analyzes the impact of a range of demographic factors on unique surgical complications within the 30-day postoperative period. We extracted data from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2017 and searched for Achilles tendon repairs using CPT codes 27650, 27652, and 27654, identifying 4,040 patients. Twenty-two demographic variables and their association with each of 4 complications were analyzed using t tests or chi-squared tests. A logistic regression was conducted to determine independent risk factors for each outcome, based on results from the bivariate analyses. Variables having p <.2 on bivariate analysis were included in the multivariate analysis of the corresponding surgical complication. Patients with open or infected wounds preoperatively were more likely to return with a postoperative surgical infection (p< .001). Likewise, each additional year of the patient's age increased their likelihood of developing a surgical infection (p= .03). Patients with "clean/contaminated" wound sites prior to repair were more likely to return for an additional service (p= .02). Furthermore, each additional inch of the patient's height (p= .03) and every additional minute of operative time increased a patient's risk of developing a new-onset deep vein thrombosis (p= .01). This study offers providers a more complete picture of which preoperative characteristics affect Achilles tendon repair patients, directing management to reduce postoperative complication rates.

Anatomic relationship of the sural nerve when performing Achilles tendon repair using the percutaneous Achilles repair system, a cadaveric study

BACKGROUND

Minimally invasive techniques for Achilles tendon repair are increasing due to reports of similar rerupture rates using open and percutaneous techniques with fewer wound complications and quicker recovery with percutaneous methods. The goal of this study was to investigate quantitatively the relationship and risk of injury to the sural nerve during Achilles tendon repair when using the Percutaneous Achilles Repair System (PARS) (Arthrex®, Naples, FL), by recording the distance between the passed needles and the sural nerve as well identifying any direct violation of the nerve with needle passage or nerve entrapment within the suture after the jig was removed. The hypothesis of the study is that the PARS technique can be performed safely and without significant risk of injury to the sural nerve.

METHODS

A total of five needles were placed through the PARS jig in each of 10 lower extremity cadaveric specimens using the proximal portion after simulation of a midsubstance Achilles tendon rupture. Careful dissection was performed to measure the distance of the sural nerve in relation to the passed needles. The sutures were then pulled out through the incision as the jig was removed from the proximal portion of the tendon and observation of the suture in relation to the tendon was documented.

RESULTS

Of the 10 cadaveric specimens, none had violation of the sural nerve. Zero of the 50 (0%) needles directly punctured the sural nerve. In addition, upon retraction of the jig, all sutures were noted to reside within the tendon sheath with no entrapment of the sural nerve noted.

CONCLUSION

This study demonstrated the variable course of the sural nerve and identifies the potential risk for sural nerve injury when using the PARS for Achilles tendon repair. However, this study provides additional evidence of safety from an anatomic standpoint that explains the outcomes demonstrated in the clinical trials. With this information the authors believe surgeons should feel comfortable they can replicate those outcomes while minimizing risk of sural nerve injury when the technique is used correctly.

Sports Medicine-Related Breast and Chest Conditions-Update of Current Literature

ABSTRACT

This article reviews the most up-to-date evidence-based recommendations pertaining to breast and upper chest conditions, specifically for the sports medicine physician. Because of the unique circumstances of the team physician, they can see a wide breadth of pathology. Athletes may not have a primary care physician and may prefer to present to their team physician for breast and upper chest conditions. It is often more comfortable and convenient for athletes to seek treatment in the team setting. Therefore, it is important that the medical professional be aware of not only common pathology but also of that which is rarer. Any delay in evaluation can result in unnecessary morbidity and lead to complications or extended time lost from sport. Consequently, it also is important to facilitate an atmosphere encouraging early presentation and workup.

Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study

INTRODUCTION

Despite the presence of various different surgical procedures, the preferable technique for repair of acute Achilles tendon ruptures is unknown and, therefore, object of discussions. The purpose of this meta-analysis was to compare clinical outcomes and complication-rates between the minimally invasive and the standard open repair of acute Achilles tendon ruptures.

MATERIALS AND METHODS

This meta-analysis was performed according to the PRISMA guidelines. In September 2019 the main databases were accessed. All clinical trials of evidence level I to III comparing minimally invasive vs. open surgery of Achilles tendon rupture were included in the present study. Only articles reporting quantitative data under the outcomes of interest were included. Missing data under the outcomes of interest warranted the exclusion from the present work. For the statistical analysis we referred to the Review Manager Software Version 5.3. (The Nordic Cochrane Centre, Copenhagen). Continuous data were analysed through the inverse variance method. For the effect estimate the mean difference was used. Dichotomous data were analysed through the Mante-Haenszel method via odd ratio effect measure. The confidence interval was set at 95% in all the comparisons. Values of P < 0.05 were considered statistically significant.

RESULTS

A total of 25 articles were included for meta-analysis. The funnel plot revealed poor data dispersion, attesting to this study a low risk of publication bias. The quality of the methodological assessment was moderate. Data from 2223 (1055 open, 1168 minimally invasive) surgical procedures were extracted. The mean follow-up was of 24.29 ± 22.4 months. The open group reported a lower value of post-operative palpable knot at last follow-up and a lower rate of sural nerve palsy. In the minimally-invasive group a shorter surgery duration and a lower rate of post-operative wound necrosis and reduced risk of wound scarring and adhesions has been evidenced. The minimally-invasive cohort detected the lowest values of superficial and deep infections. In both groups no significant difference was shown in re-rupture rate.

CONCLUSIONS

Compared to the minimally-invasive Achilles tendon reconstruction, the open procedure evidenced a lower rate of sural nerve palsy and postoperative palpable knot, whereas in the minimally-invasive reconstruction group quicker surgery duration, a lower rate of post-operative wound necrosis, superficial and deep infections and less scar tissue adhesions could be observed. No relevant discrepancies were detected among the two techniques in terms of post-operative re-rupture.

Liquid Poly-N-acetyl Glucosamine (sNAG) Improves Achilles Tendon Healing in a Rat Model

The Achilles tendon, while the strongest and largest tendon in the body, is frequently injured. Even after surgical repair, patients risk re-rupture and long-term deficits in function. Poly-N-acetyl glucosamine (sNAG) polymer has been shown to increase the rate of healing of venous leg ulcers, and use of this material improved tendon-to-bone healing in a rat model of rotator cuff injury. Therefore, the purpose of this study was to investigate the healing properties of liquid sNAG polymer suspension in a rat partial Achilles tear model. We hypothesized that repeated sNAG injections throughout healing would improve Achilles tendon healing as measured by improved mechanical properties and cellular morphology compared to controls. Results demonstrate that sNAG has a positive effect on rat Achilles tendon healing at three weeks after a full thickness, partial width injury. sNAG treatment led to increased quasistatic tendon stiffness, and increased tangent and secant stiffness throughout fatigue cycling protocols. Increased dynamic modulus also suggests improved viscoelastic properties with sNAG treatment. No differences were identified in histological properties. Importantly, use of this material did not have any negative effects on any measured parameter. These results support further study of this material as a minimally invasive treatment modality for tendon healing.

Accessory Flexor Hallucis Longus Tendon Discovered During Achilles Tendon Reconstruction: A Report of 2 Cases

CASE

We present 2 cases of Achilles reconstruction using flexor hallucis longus (FHL) tendon transfer for the augmentation of Achilles surgical repair during which the patients were noted to have accessory FHL tendons. Structure identification in the posterior ankle is important because the neurovascular bundle is in close proximity to the FHL; knowledge of the anatomy of variations is helpful, and 2 cases of accessory tendon variation are reported.

CONCLUSIONS

Achilles tears are typically primarily repaired. Some patients may require augmentation with allograft or autograft transfer of the FHL tendon. Accessory FHL tendons discovered during posterior approach to the Achilles has not been described in the literature.

Assessing the Readability of Online Information About Achilles Tendon Ruptures

The American Medical Association (AMA) and National Institutes of Health (NIH) currently suggest that health care materials be written at a sixth-grade reading level. Our study investigates the readability of online information on Achilles rupture and reconstruction. Achilles tendon rupture, Achilles tendon repair, and Achilles tendon reconstruction were queried using advanced search functions of Google, Bing, and Yahoo!. Individual websites and text from the first 3 pages of results for each search engine were recorded and categorized as physician based, academic, commercial, government and nongovernmental organization, or unspecified. Individual readability scores were calculated via 6 different indices: Flesch-Kincaid grade level, Flesch Reading Ease, Gunning Fog, SMOG, Coleman-Liau index, and Automated Readability Index along with a readability classification score and average grade level. A total of 56 websites were assessed. Academic webpages composed the majority (51.8%), followed by physician-based sources (32.1%). The average overall grade level was 10.7 ± 2.54. Academic websites were written at the highest-grade level (11.5 ± 2.77), significantly higher than physician-based websites (P = .040), and only 2 were written at, or below, a sixth-grade reading level. Currently, online information on Achilles tendon rupture and reconstruction is written at an inappropriately high reading level compared with recommendations from the AMA and NIH.Level of Evidence: Level IV.

Patient perception of Achilles tendon rupture treatment

The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopedic surgeons. Many patients' understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with demographic information and the health literacy of the patient. Patients presenting with an Achilles tendon injury were asked to fill out a demographic form, the Literacy in Musculoskeletal Problems (LiMP) survey, to assess musculoskeletal health literacy, and a 22-question survey on ATRs designed to assess patient knowledge and perception of ATRs. Seventy percent of patients responded that surgery with or without other modalities is the most appropriate treatment for ATRs, while only 20% of patients responded that nonoperative treatment is most appropriate. Perceptions of treatment were not associated with demographic data or LiMP scores and appear to be biased to some degree towards surgery. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive.

Construction of Microunits by Adipose-Derived Mesenchymal Stem Cells Laden with Porous Microcryogels for Repairing an Acute Achilles Tendon Rupture in a Rat Model

Objective

Tissue engineering approaches seem to be an attractive therapy for tendon rupture. Novel injectable porous gelatin microcryogels (GMs) can promote cell attachment and proliferation, thus facilitating the repair potential for target tissue regeneration. The research objectives of this study were to assess the efficacy of tissue-like microunits constructed by multiple GMs laden with adipose-derived mesenchymal stem cells (ASCs) in accelerated tendon regeneration in a rat model.

Methods

Through a series of experiments, such as isolation and identification of ASCs, scanning electron microscopy, mercury intrusion porosimetry (MIP), laser scanning confocal microscopy and the CCK-8 test, the biocompatibility of GMs was evaluated. In an in vivo study, 64 rat right transected Achilles tendons were randomly divided into four groups: the ASCs+GMs group (microunits aggregated by multiple ASC-laden GMs injected into the gap), the ASCs group (ASCs injected into the gap), the GMs group (GMs injected into the gap) and the blank defect group (non-treated). At 2 and 4 weeks postoperatively, the healing tissue was harvested to evaluate the gross observation and scoring, biomechanical testing, histological staining and quantitative scoring. Gait analysis was performed over time. The 64 rats were randomly assigned into 4 groups: (1) micro-unit group (ASCs+GMs) containing ASC (10⁵)-loaded 120 GMs in 60 μL DMEM; (2) cell control group (ASCs) containing 10⁶ ASCs in 60 μL DMEM; (3) GM control group (GMs) containing 120 blank GMs in 60 μL DMEM; (4) blank defect group (Defect) containing 60 μL DMEM, which were injected into the defect sites. All animals were sacrificed at 2 and 4 weeks postsurgery (Table 1).

Results

In an in vitro study, GMs (from 126 μm to 348 μm) showed good porosities and a three-dimensional void structure with a good interpore connectivity of the micropores and exhibited excellent biocompatibility with ASCs. As the culture time elapsed, the extracellular matrix (ECM) secreted by ASCs encased the GMs, bound multiple microspheres together, and then formed active tendon tissue-engineering microunits. In animal experiments, the ASCs+GMs group and the ASCs group showed stimulatory effects on Achilles tendon healing. Moreover, the ASCs+GMs group was the best at improving the macroscopic appearance, histological morphology, Achilles functional index (AFI), and biomechanical properties of repair tissue without causing adverse immune reactions.

Conclusion

Porous GMs were conducive to promoting cell proliferation and facilitating ECM secretion. The ASCs-GMs matrices showed an obvious therapeutic efficiency for Achilles tendon rupture in rats.

Improving the regenerative microenvironment during tendon healing by using nanostructured fibrin/agarose-based hydrogels in a rat Achilles tendon injury model

AIMS

Achilles tendon injuries are a frequent problem in orthopaedic surgery due to their limited healing capacity and the controversy surrounding surgical treatment. In recent years, tissue engineering research has focused on the development of biomaterials to improve this healing process. The aim of this study was to analyze the effect of tendon augmentation with a nanostructured fibrin-agarose hydrogel (NFAH) or genipin cross-linked nanostructured fibrin-agarose hydrogel (GP-NFAH), on the healing process of the Achilles tendon in rats.

METHODS

NFAH, GP-NFAH, and MatriDerm (control) scaffolds were generated (five in each group). A biomechanical and cell-biomaterial-interaction characterization of these biomaterials was then performed: Live/Dead Cell Viability Assay, water-soluble tetrazolium salt-1 (WST-1) assay, and DNA-released after 48 hours. Additionally, a complete section of the left Achilles tendon was made in 24 Wistar rats. Animals were separated into four treatment groups (six in each group): direct repair (Control), tendon repair with MatriDerm, or NFAH, or GP-NFAH. Animals were euthanized for further histological analyses after four or eight weeks post-surgery. The Achilles tendons were harvested and a histopathological analysis was performed.

RESULTS

Tensile test revealed that NFAH and GP-NFAH had significantly higher overall biomechanical properties compared with MatriDerm. Moreover, biological studies confirmed a high cell viability in all biomaterials, especially in NFAH. In addition, in vivo evaluation of repaired tendons using biomaterials (NFAH, GP-NFAH, and MatriDerm) resulted in better organization of the collagen fibres and cell alignment without clinical complications than direct repair, with a better histological score in GP-NFAH.

CONCLUSION

In this animal model we demonstrated that NFAH and GP-NFAH had the potential to improve tendon healing following a surgical repair. However, future studies are needed to determine the clinical usefulness of these engineered strategies. Cite this article: Bone Joint J 2020;102-B(8):1095-1106.

Prognosis of elite basketball players after an Achilles tendon rupture

Objective

Professional Basketball players are at high risk of Achilles tendon rupture. Despite this, there remains limited research into the factors affecting rehabilitation and the long term outcomes of these players. Our aim is to quantify the effect of a player’s Achilles tendon rupture on their post-injury performance, and also to explore for correlations between their recovery timeline and pre-injury characteristics. Creation of an injury timeline of past incidents will allow injured players to better track their progress and also inform them about the probable impact on their careers.

Hypothesis

Players with Achilles tendon rupture injury will exhibit decreased performance compared to their pre-injury self and their non-injured peers after recovery.

Methods

Professional basketball players who sustained a unilateral Achilles tendon rupture from 1992 to 2016 were collected. 12 players met our inclusion criteria and their Player Efficiency Ratings (PER) were obtained as primary outcome measures; matched controls were chosen based on the PER, Age and playing position. The players’ index season PER was compared against the PER during the 10 games immediately following the players’ return and the PER of their post-injury peak performing season. The same data analysis was performed against their control group. To investigate the factors affecting the recovery and long-term consequences of their injury, we correlated the variables of Age, BMI, Time of Injury and pre-injury PER with the player’s time to return to play and their post-injury PER.

Results

2 out of 12 players failed to return to playing in the elite professional league following an Achilles Tendon Rupture, others returned after a mean recovery time of 10 months. When compared to players’ index PER, the mean PER reduction during the 10 games immediately following the players’ return was 7.15 (P < .000). Players on average took 1.8 seasons to reach their post-injury peak performance, with only 1 player returning to his pre-injury performance. Others suffered a mean PER reduction of 3.5 (P = .004) when compared to their index PER and 5.4 (P = .045) against their matched controls.

Conclusion

Achilles tendon rupture can be a career-ending injury for professional basketball players. They are expected to miss 10 months for rehabilitation and reach their post-injury peak performance level at the 2nd season back. The post-injury peak performance is significantly worse than the pre-injury level, but is similar to matched non-injured players.

Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis

BACKGROUND

While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments.

METHODS

Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments.

RESULTS

A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically.

CONCLUSION

The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.

Effect of low intensity photobiomodulation associated with norbixin-based poly (hydroxybutyrate) membrane on post-tenotomy tendon repair. In vivo study

Purpose:

To evaluate the in vivo response of photobiomodulation therapy associated with norbixin-based poly(hydroxybutyrate) membrane (PHB) in tenotomized calcaneal tendon.

Methods:

Thirty rats were randomly allocated to six groups (n=5 each): LED groups (L1, L2 and L3) and membrane + LED groups (ML1, ML2 and ML3). The right calcaneal tendons of all animals were sectioned transversely and were irradiated with LED daily, one hour after surgery every 24 hours, until the day of euthanasia. At the end of the experiments the tendons were removed for histological analysis.

Results:

The histological analysis showed a significant reduction in inflammatory cells in the ML1, ML2 and ML3 groups (p=0.0056, p=0.0018 and p<0.0001, respectively) compared to those in the LED group. There was greater proliferation of fibroblasts in the ML1 (p<0.0001) and L3 (p<0.0001) groups. A higher concentration of type I collagen was also observed in the ML1 group (p=0.0043) replacing type III collagen.

Conclusion:

Photobiomodulation in association with norbixin-based PHB membrane led to control of the inflammatory process. However, it did not favor fibroblast proliferation and did not optimize type I collagen formation in the expected stage of the repair process.