Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

PURPOSE

After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport.

METHODS

The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias.

RESULTS

Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks.

CONCLUSION

In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function.

LEVEL OF EVIDENCE

Level IV.

Achilles Tendon Reconstruction Using a Hamstring Tendon Autograft for Chronic Rupture of the Achilles Tendon in Patients Over 70 Years of Age: A Retrospective Case Series

Reconstruction techniques using autologous hamstring tendons were generally applied for chronic Achilles tendon rupture with a large defect size. Previous studies have reported good clinical results of this technique for young or middle-aged patients, however, the clinical outcomes in older patients have been unclear. This retrospective case series reviewed four male patients aged >70 years (mean age, 78.5 years) who underwent Achilles tendon reconstruction using the hamstring tendon autograft for chronic rupture of the Achilles tendon with a large tendon defect. The proximal-distal length between the healthy tendon stumps was measured using sagittal T2-weighted magnetic resonance imaging (MRI). The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and postoperative complications were evaluated. The duration from the traumatic event or appearance of symptoms to surgery was 3.8 (range, 2-6) months. The mean measured gap between the healthy tendon stumps was 67.5 mm on MRI. The AOFAS ankle-hindfoot score improved from 67.3 to 99.5 at the mean follow-up period of 40.3 (range, 23-75) months. No donor site morbidity was observed in all patients. Re-rupture was detected at the five-month follow-up in one patient who had removed a hinged ankle-foot orthosis with adjustable heel wedges without permission. Achilles tendon reconstruction using a hamstring tendon is a viable option for treating selected patients with chronic rupture of the Achilles tendon with a large tendon defect even in older patients. To improve clinical outcomes, a better understanding should be provided to family members as well as older patients regarding the postoperative rehabilitation program.

Global trends in research of achilles tendon injury/rupture: A bibliometric analysis, 2000–2021

Background

The Achilles tendon is the strongest and most susceptible tendon in humans. Achilles tendon injuries and ruptures have gradually attracted research attention. However, a bibliometric analysis of global research in this field is lacking. This study involved a bibliometric analysis of the developmental trends and research hotspots in Achilles tendon injuries/ruptures from 2000 to 2021.

Methods

Articles published between 2001 and 2021 were retrieved from an extended database of the Science Citation Index using Web of Science. VOSviewer and CiteSpace were used to analyze the relationships between publications, countries, institutions, journals, authors, references, and keywords.

Results

This study included 3,505 studies of 73 countries, 3,274 institutions, and 12,298 authors and explored the cooperation between them and the relationships between citations. Over the past 22 years, the number of publications has significantly increased. Foot Ankle International has published the most papers on Achilles tendon injuries/ruptures, and British Journal of Sports Medicine is the most famous journal. Re-rupture, exosomes, acute Achilles tendon rupture, and tendon adhesions gradually become the research focus over the past few years.

Conclusion

Achilles tendon injury and rupture are important research topics. A vast number of newly published papers on this topic have demonstrated that clinicians and researchers are interested in their study. Over time, these recent studies will be widely cited; therefore, this bibliometric analysis should be constantly updated.

Dual Semitendinosus Allograft Reconstruction of Chronic Achilles Tendon Ruptures: Operative Technique and Outcomes

BACKGROUND

Dual semitendinosus allograft reconstruction of chronic Achilles tendon ruptures has several potential benefits including superior tensile strength compared with a turndown construct and avoidance of the morbidity and operative time associated with autograft augmentation. We present a series of chronic Achilles tendon ruptures reconstructed with dual semitendinosus allograft.

METHODS

We retrospectively reviewed the charts of patients aged 18 years and older who underwent reconstruction of chronic Achilles tendon ruptures using dual semitendinosus allograft. The primary outcome of this study was to evaluate the need for revision surgery. Secondary outcomes included patient-reported outcomes, for which Achilles Tendon Rupture Scores (ATRS) were collected at final follow-up. Nine patients with a mean age of 58.9 (range, 43-75) years met inclusion criteria.

RESULTS

Median follow-up was 66 months (range, 27-121 months). One patient (11.1%) required revision reconstruction after sustaining graft failure 9.5 years after her index procedure, and 1 patient reported a poor ATRS score at the 27-month final follow-up despite an intact surgical repair. At final follow-up, no patient required the use of an assistive device for ambulation or a walking boot. The median ATRS at final follow-up was 93 (range, 30-100).

DISCUSSION

Good clinical outcomes without rerupture were observed in 7 of 9 patients (77.8%) at short- to midterm follow-up, suggesting that dual semitendinosus allograft reconstruction is a viable option for the reconstruction of chronic Achilles tendon tears.

LEVEL OF EVIDENCE

Level IV, case series.

[V-Y plasty combined with gastrocnemius aponeurosis turndown repairing the Myerson type chronic Achilles tendon rupture]

Objective

To investigate the clinical application and effectiveness of V-Y plasty combined with gastrocnemius aponeurosis turndown in the repair of Myerson type Ⅲ chronic Achilles tendon rupture combined with large tendon defect.

Methods

Between February 2008 and July 2019, 25 patients underwent the V-Y plasty combined with gastrocnemius aponeurosis turndown to treat the Myerson type Ⅲ chronic Achilles tendon rupture. There were 21 males and 4 females. The age ranged from 17 to 56 years, with an average of 34.3 years. Achilles tendon rupture was caused by sports injury in all patients, and the duration from Achilles tendon rupture to operation was 31-70 days, with an average of 53.9 days. After resection of fibrous scar tissue, the distance of Achilles tendon defect was 7-12 cm, with an average of 9.04 cm. The clinical results were evaluated by the Achilles tendon total rupture score (ATRS), American Orthopaedic Foot and Ankle Society (AOFAS) score, dorsiflexion and heel raise height before and after operation.

Results

The donor and recipient wounds of all 25 cases healed by first intention after operation. All patients were followed up 24 months. During the follow-up, 3 patients developed mild wound infection, which was cured after anti-infection treatment. One patient had Achilles tendon exposure, which was cured after local flap transfer and repair. Ultrasound and MRI reexamination at 3-12 months after operation showed no Achilles tendon elongation, adhesion, or re-rupture. At 24 months after operation, the ATRS score, AOFAS score, dorsiflexion and heel raise height of affected side significantly improved when compared with those before operation (P<0.05). However, the dorsiflexion and heel raise height of affected side were still significantly worse than those of the healthy side (P<0.05).

Conclusion

V-Y plasty combined with gastrocnemius aponeurosis turndown to repair the chronic Achilles tendon rupture can achieve good effectiveness, and the Achilles tendon function significantly improved after repair. However, the procedure is more invasive and has a long duration of intraoperative wound exposure, causing an increased risk of infection, and the aesthetic is not good.

Reconstruction of chronic tibialis anterior tendon ruptures using a free anterior half of a peroneus longus tendon autograft: A technical note

Purpose: Chronic rupture of the tibialis anterior (TA) tendon is rare. Several reconstruction techniques have been introduced. However, to the best of our knowledge, the use of a free anterior half of a peroneus longus tendon (AHPLT) autograft has not been reported for reconstruction of TA tendon rupture. This study aimed to describe the surgical technique and present the clinical outcomes of reconstruction of the chronic TA tendon ruptures using an AHPLT autograft. Methods: Between September 2013 and April 2019, five patients with chronic TA tendon rupture were surgically treated by reconstruction using an AHPLT autograft. The AHPLT could be easily harvested percutaneously with a tendon stripper from the ipsilateral lower leg around the reconstruction site. The study included four men and one woman, with a mean age of 43.8 (range: 23-65) years. Results: At a mean follow-up period of 42.8 (range; 12-70) months, the mean Foot Function Index value significantly improved from 53.6 ± 19.8 preoperatively to 25.8 ± 20.8 postoperatively (p = .04). None of the patients had morbidities (such as nerve injury, delayed tendon ruptures, or tenosynovitis) around the AHPLT donor site. Three patients were very satisfied, two patients were satisfied, and one patient was fair with the results. Conclusions: Reconstruction of chronic TA tendon ruptures using a free AHPLT autograft could be successfully performed with satisfactory clinical outcomes and minimal donor site morbidities. Future studies with a larger population size and a comparative group are warranted to confirm these findings.

Trends in hospitalization for paediatric flatfoot: an Italian nationwide study from 2001 to 2016

Background

Flatfoot is a common condition in young patients, but usually resolves by adolescence. This study aimed to estimate annual trend hospitalizations for flatfoot in Italian paediatric population from 2001 to 2016.

Methods

Data of this study were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health regarding the years of this paper (2001–2016). The yearly number of hospital admission for flatfoot, the percentage of males and females, the average age, the average days of hospitalization, primary diagnoses and primary procedures in the whole Italian population were calculated using descriptive statistical analyses.

Results

109,300 hospitalizations for flatfoot of young patients were performed during this period. 59.3% of patients were male and 40.7% female of the 10–14 years-old age class. The average days of hospitalization stay were 1.73 ± 1.27 days. The data highlights that the burden of flatfoot surgery is growing and affecting the healthcare system. The mean rate of hospital admissions in Italy for flatfoot in the young population was 82.14 for 100,000 inhabitants of the same age class.

Conclusions

The data highlights that the cases of flatfoot surgery increased from 2001 to 2016. The most common treatment was the “Internal Fixation Of Bone Without Fracture Reduction, Tarsals And Metatarsals followed by Subtalar Fusion and Arthroereisis. Further prospective studies on this topic may be conducted to improve the evidence of the results.

Patient reported outcomes and satisfaction following single incision Flexor Hallucis Longus (FHL) augmentation for chronic Achilles tendon pathologies

BACKGROUND

Various procedures exist to augment or reconstruct the Achilles tendon (AT) in patients suffering from chronic pathologies. The aim of this study is to assess patient reported outcomes and satisfaction following single incision FHL augmentation using a short tendon harvest with interference screw fixation.

METHODS

This is a multicentre case series where postoperative patient reported outcome and satisfaction scores were collected on 30 patients. Outcome measures included EQ-5D, EQ-VAS, Achilles Tendon Rupture Scores (ATRS), and satisfaction scores. Scores were also collected on the unaffected limbs for comparison.

RESULTS

Mean patient age was 61 years (range 40-79, SD 11). Mean EQ-5D index value was 0.750 (0.100-1.00, SD 0.238), and mean EQ-VAS score was 74 (36-99, SD 15), at a mean follow-up of 57 months (4-118, SD 32). For patients with ≥24 months' follow-up, a mean deficit of 16 ATRS points was found between the operated and unaffected limb. Overall satisfaction was over 86%. In cases of chronic AT rupture, younger age and increasing time from initial injury to surgery were predictors of greater residual deficit. No serious complications or failures occurred.

CONCLUSIONS

FHL augmentation using short tendon harvest and interference screw fixation is a safe treatment option. It appears to take at least 24 months to functionally recover following this procedure, and despite a residual function deficit, there is a high level of patient satisfaction. Further studies are required to determine optimal patient selection and timing of surgery.

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.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-021-05102-5.

Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon

Background:

The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture.

Methods:

A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up.

Results:

Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up ( P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively ( P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery.

Conclusion:

The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery.

Level of Evidence:

Level IV, retrospective case series.

2017 Marathon of Rome: Anthropometry and Sport Profile in 350 Runners and Association With Achilles and Patellar Tendinopathy

BACKGROUND

Achilles and patellar tendinopathy are common in runners. Despite the relevance of the problem, causative factors remain poorly understood. This cross-sectional study evaluated the association between Achilles and patellar tendinopathy and age, sex, weight, height, number of marathons, and impact profile in runners who participated in the 2017 Marathon of Rome.

METHODS

At the 2017 Marathon of Rome, 350 athletes (256 men and 94 women; mean age: 44.8 years, range 12-80 years) filled in the VISA-A and VISA-P questionnaires. A fully trained orthopedic surgeon made a diagnosis of Achilles and patellar tendinopathy according to clinical criteria.

RESULTS

Ninety-five participants were diagnosed with Achilles tendinopathy and 96 with patellar tendinopathy. There was evidence of a statistically significant positive association between age and Achilles and patellar tendinopathy, with no effect of sex, weight, and height on the presence of Achilles tendinopathy. There was no evidence of a statistically significant positive association between the number of marathons and impact profile and VISA-A score. There was a statistically significant association between VISA-P score and impact profile. Finally, there was evidence of a statistically significant positive association between VISA-A score and VISA-P score (P = 0.007).

CONCLUSIONS

In marathon runners, there was no evidence of a statistically significant association between sex, weight, height, number of marathons, and Achilles and patellar tendinopathy. However, age was associated with Achilles and patellar tendinopathy, and impact profile was associated with patellar tendinopathy.

Less Invasive Fixation of Acute Avulsions of the Achilles Tendon: A Technical Note

Purpose: Nowadays, surgical treatment of acute avulsions of the Achilles tendon represents a hard challenge. There is often the possibility that the calcaneus remains completely uncovered from the tendon, making the reinsertion of its distal stub complex. At the same time, the standard open surgical technique could cause difficult wound healing because of the weak blood supply, the increasing possibility of rupture, and the bacterial contamination. To overcome these risks, less invasive procedures should be considered. Methods: We developed an innovative minimally invasive procedure for fixation of acute avulsions of the Achilles tendon employing an integration of four longitudinal stab incisions and one distal semicircular Cincinnati incision. In this way, the distal Achilles tendon stub and the calcaneal insertion are exhibited. Results: We basted the tendon through percutaneous sutures performed across the four stab incisions with a Mayo needle threaded with Ultrabraid. The procedure is repeated with another loop of Ultrabraid. After having bruised the calcaneus bone insertion of the tendon, two sites for two suture anchors were prepared using a specific hole preparation device for the anchors’ footprint. Finally, we placed two suture anchors to reinsert the tendon to the calcaneal insertion. Conclusion: Our new less invasive technique is a promising alternative optional procedure for the Achilles tendon (AT) avulsion repair allowing clear exposure of the Achilles tendon insertion, maintaining the longitudinal wholeness of the dermis, and minimizing possible associated complications.

Epidemiology of Achilles tendon surgery in Italy: a nationwide registry study, from 2001 through 2015

Background

This study aims (1) to estimate the yearly number of Achilles tendon (AT) surgeries in Italy from 2001 to 2015 based on official hospitalization records; (2) to investigate the eventual presence of geographical variation in equity in access to AT surgery between three macroregions of Italy (North, Center and South); (3) to perform statistical projections of the number of AT procedure volumes and rates based on these data.

Methods

We analysed the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health for a 15-year period, from 2001 through 2015. These data are anonymous and include the patient’s age (evaluated in the class of age), sex, census region, the region of hospitalization, length of the hospitalization, public or private reimbursement and diagnosis.

Results

During the 15-year study period, 118,652 AT repair were performed in Italy, whose peak of incidence was in 2010. More than half of AT repairs was performed in the North of Italy (52.1%), while 27.2% was performed in the South of Italy and 20.6% Center of Italy. The projection model predicted a slight growth of 2.65% in 2025 in comparison with 2015.

Conclusion

The current study provides detailed information about the national population-weighted incidence of AT surgery, distribution and projection. The peak of average age was 35–45 year. The majority of AT procedures was performed in the North of Italy. The projection model predicts a slight growth of AT surgery by 2025. Furthermore, this 15-year nationwide registry study shows that the age of incidence of AT injuries shifted from 30 to 40 to 35–45 years compared to the available literature. The higher prevalence of AT surgery was found in men during the working age. Moreover, a low rate of procedures in pediatric and elder age classes was observed.

Clinical outcomes of chronic Achilles tendon rupture treated with flexor hallucis longus grafting and flexor hallucis longus grafting plus additional augmentation: A meta-analysis

BACKGROUND

The treatment of chronic Achilles tendon rupture is still controversial. Many surgical procedures have been proposed and claim to have good post-operative clinical outcomes. These techniques include direct repair, V-Y flap, turndown flap, peroneus brevis tendon graft, flexor digitorum longus graft, FHL graft, semitendinosus graft, gracilis tendon graft or synthetic material. The two surgical techniques that are widely used include FHL grafting and the combination of FHL grafting plus additional augmentation. This meta-analysis was conducted with the purpose of comparing clinical outcomes of flexor hallucis longus (FHL) grafting and the combination of FHL grafting with additional augmentation techniques in the treatment of chronic Achilles tendon rupture.

METHODS

Systematic literature searches were conducted on Medline, Embase and Scopus from their inception to April 4, 2019, and proceedings of reference list and scientific meetings were also searched. Relevant clinical studies (e.g., observational, cross-sectional, cohort or randomized controlled trial (RCT)) that reported AOFAS (American Orthopedic Foot Ankle Score) and postoperative complications of either technique were identified.

RESULTS

Six studies (N = 68) were included for the analysis of FHL, and six studies (N = 124) were included for analysis of FHL with augmentation. A pooling of mean and standard deviation of preoperative and postoperative AOFAS were 57.09 (3.63), 92.97 (22.67) in FHL group and 66.92 (3.16), 95.25 (4.71) in FHL with additional augmentation group respectively. The pooled UMD of AOFAS in FHL with additional augmentation were 2.28 (-1.86, 6.42) scores higher when compared to the FHL group. The prevalence of complications in FHL and FHL with additional augmentation were 14 (N = 120) and 10 (N = 63) patients. The chance of having complications of FHL with additional augmentation group was 0.74 (95% CI: 0.35, 1.56) lower than FHL group. However, there is no statistically significant difference.

CONCLUSIONS

FHL with additional augmentation group has higher foot function scores (AOFAS) and lower complications when compared to the FHL group. However this did not reach to statistically significant. Further research that assesses a larger sample size of RCTs is necessary to further evaluate FHL with additional augmentation and FHL in the treatment of chronic Achilles tendon rupture.

Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears

INTRODUCTION

Very distal tears of the Achilles tendon are uncommon, and poor quality tendinous tissue of the calcaneal stump can compromise healing. Little has been published about the characteristics and surgical management of such injuries. We present a surgical technique, developed by the senior author, to restore continuity of the gastrosoleus-Achilles tendon-calcaneus complex using a free ipsilateral semitendinosus graft, and clinical outcomes of a case series of 28 consecutive patients. Our hypothesis was that this is a safe technique, and patients can return to pre-injury occupation and athletic activities.

PATIENTS AND METHODS

A total of 28 patients (mean age 46 years) underwent minimally invasive reconstruction using a free ipsilateral semitendinosus graft for acute insertional rupture of tendo Achillis. The procedure required two small incisions along the course of the Achilles tendon, and one posteromedial incision at level of the ipsilateral knee to harvest the semitendinosus tendon. Patients were assessed at minimum 2 years (range, 2-2.5 years) following the index procedure.

RESULTS

The median Achilles tendon Rupture Score (ATRS) at the latest follow-up was 88. Two patients developed a superficial wound infection. All patients returned to their preinjury occupation, whilst 22 out of 28 patients (79%), returned to their preinjury level of physical activity at a mean of 6.7 months after surgery, reporting good or excellent overall satisfaction in 88.5% of cases.

CONCLUSION

This minimally invasive technique was safe, and allowed most of patients to return to preinjury daily and sport activities within 9 months from surgery.

Repair of Achilles sleeve avulsion: a new transosseous suture technique

BACKGROUND

Achilles sleeve avulsion usually occurs from pre-existing insertional Achilles tendinopathy, leaving a calcific spur at the insertional site. The purpose of this study was to introduce a new technique using the spur base on the insertional site to drill the suture tunnel to repair Achilles sleeve avulsion.

METHODS

In total, 11 patients diagnosed with Achilles sleeve avulsion underwent this new surgical technique and were followed for a mean time of 40 months. Clinical outcomes were measured using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Tegner score, and time taken to return to activities. Preoperative and postoperative MRI, the ability to perform heel rise, and complications were also evaluated.

RESULTS

All cases (11/11) had insertional Achilles tendinopathy with calcific spur formation on the tendon's insertion. At final follow-up, the average VAS score improved from 5.3 to 0.1, AOFAS score improved from 44.8 to 97.9, VISA-A score improved from 23.6 to 96.6, and Tegner score improved from 0.9 to 4.9. Tendinopathy symptoms were eliminated. Patients returned to daily activities, work, and sports 3.5 months, 2.8 months, and 12.3months after operation, respectively. Patients took an average of 18.1 weeks after operation to perform the single heel rise test. No severe complications such as infection and rerupture were observed.

CONCLUSION

Our new transosseous suture technique is a promising alternative option in treating Achilles sleeve avulsion. More cases and longer follow up are needed in order to find the best reconstructive option for this pathology.

LEVELS OF EVIDENCE

Level IV.

Tendon regeneration and muscle hypotrophy after isolated Gracilis tendon harvesting - a pilot study

Purpose

The gracilis tendon (GT) is a commonly used autologous graft in Orthopaedic surgery. The majority of information on knee function and outcomes after hamstring harvest is related to both semitendinosus and GT harvest. Little is known regarding isolated harvest of a GT. It was hypothesized that isolated GT harvest would lead to altered gait patterns (e.g. augmented anterior-posterior translation or rotation in the tibiofemoral joint) and consequently a higher prevalence of cartilage lesions and meniscal tears in knees.

Methods

GT harvesting was performed on patients with chronic acromioclavicular joint instability without previous knee injuries or surgeries. MRI of both knees and thighs were performed. Knee MRI were evaluated using the Whole-Organ Magnetic Resonance Imaging Score (WORMS). Inter- and intraobserver reliabilities, cross-sectional areas of different muscles, fatty infiltration of the gracilis muscle (GM) and GT regeneration were evaluated. The contralateral limb served as reference. The observers were blinded towards the identity of the patients and the operatively treated side.

Results

After a mean time of 44 months after surgery testing was performed on 12 patients. No significant side-to-side differences were found using WORMS, although there was a trend towards increased cartilage lesions after GT harvest (median healthy knee 4.8 and GT harvested knee 7.8 p = 0.086). Inter- and intraobserver repeatability was high with 0.899 (95% confidence interval (CI) 0.708–0.960) and 0.988 (95% CI 0.973–0.995), respectively. A significant hypotrophy of the GM with a mean decrease of 25.3%, 18.4% and 16.9% occurred at 25% (p = 0.016), 50% (p = 0.007) and 75% (p = 0.002) of the length of the femur from distal. No compensatory hypertrophy of other thigh muscles or increased fatty infiltration of the GM was found. Tendon regeneration took place in eight out of 12 patients. In case of regeneration, the regenerated tendon inserted in a more proximal place.

Conclusion

Isolated harvest of the GT for shoulder procedures did not affect knee MRI significantly indicating therefore in general suitable graft utilization for surgeries outside of the knee. GT regenerated in most patients with just a more proximal insertion and a hypotrophy of the muscle belly.

Isolated gracilis tendon harvesting is not associated with loss of strength and maintains good functional outcome

PURPOSE

The gracilis tendon is a commonly used autologous graft. Most information on knee function and outcomes after its harvest is related to both semitendinosus- and gracilis tendon harvest. Therefore this study analyzed the effect of isolated gracilis tendon harvest from healthy, uninjured knees on thigh muscle strength and patient reported outcome measures (PROMs).

METHODS

Stabilization of the acromioclavicular joint because of chronic instability was performed with autologous gracilis tendon in 12 patients. After a mean of 44 ± 25 months after surgery, isokinetic peak-torque measurements of specific functions of the gracilis muscle were performed: knee flexion in a sitting position (flexion angles 0-90°) and in prone position (flexion angles > 70°), internal tibial rotation and hip adduction. The contralateral limb was control. Knee specific PROMs were collected including IKDC-2000 subjective evaluation form, Lysholm score, the Marx Activity Rating Scale and SF-36 health survey.

RESULTS

No significant side-to-side differences were found regarding torque measurements. Excellent results were shown regarding the PROMs, which even in terms of IKDC-2000 (97 vs. 82 points, p = 0.001) exceeded significantly the age- and gender matched reference-data.

CONCLUSION

Isolated gracilis tendon harvesting was not associated with loss of strength in knee flexion, internal tibial rotation and thigh adduction. Additionally, good functional outcome as well as excellent knee-specific subjective outcome was found.

LEVEL OF EVIDENCE

III.

Minimally invasive reconstruction technique for chronic Achilles tendon tears allows rapid return to walking and leads to good functional recovery

PURPOSE

Chronic Achilles tendon tears, including chronic ruptures with end gap over 6 cm making end-to-end suturing impossible, can be treated with autologous hamstring graft reconstruction. The primary goal of this study was to present the biomechanical and long-term clinical results of recently developed minimally invasive Achilles tendon reconstruction technique.

METHODS

Minimally invasive Achilles tendon reconstruction was applied to 8 foot and ankle cadaveric specimens as well as 18 patients with chronic Achilles tendon tears. Repaired cadavers were subjected to the biomechanical testing using a cyclic loading protocol. Patients with reconstructed Achilles tendon were subjected to the clinical, functional and isokinetic tests at 12 months after the treatment.

RESULTS

All of tested Achilles cadaveric specimens survived 2 loading blocks (250 cycles of 10-100 N load followed by additional 250 cycles of 10-200 N load). With three specimens, it was possible to perform the third cyclic loading block with 20-300 N load and two specimens survived the fourth block with 20-400 N load. Therefore, a mean number of 838 cycles (±178) within the range of 509-1000 was recorded. Two specimens which survived all 1000 cycles were pulled to failure at 25 mm/s rate. The results obtained in the load to failure testing were as follows: 398 N and 608 N of maximum load. The results of functional heel rise endurance test and single leg hop for distance test indicated a decrease in the endurance and strength of the injured limb. However, the results of the weight-bearing lunge tests indicated no tendency for elongation of the Achilles tendon. A comparative analysis of the isokinetic test results for the non-injured and injured limb was revealed no statistically significant differences for every isokinetic test (n. s.), with significant difference for isometric strength parameters (p = 0.0006).

CONCLUSIONS

The results of the biomechanical tests as well as 1-year extensive functional, clinical and isokinetic results of the minimally invasive technique for chronic Achilles tendon tears are encouraging. Patients returned to their normal physical activity, including sport pre-injury level in most cases.

LEVEL OF EVIDENCE

III.

Comparison of Gastrocnemius Turn Flap and Hamstring Graft for the Treatment of Kuwada Type 3 Chronic Ruptures of the Achilles Tendon: A Retrospective Study

Background:

Chronic Achilles tendon rupture is challenging to repair, and many procedures have been suggested to fill the gap that separates the distal and proximal ends of the ruptured tendon.

Purpose:

To compare clinical outcomes between the free hamstring graft (HG) and gastrocnemius turn flap (GTF) procedures in the treatment of chronic Achilles tendon rupture.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective study included 26 patients (25 males, 1 female; mean age, 36.7 years; range, 22-53 years) with Kuwada type 3 chronic rupture of the Achilles tendon. A total of 11 patients underwent GTF surgery, whereas 15 patients underwent HG surgery. Follow-up assessments were conducted at 3, 6, and 12 months postoperatively.

Results:

The complication rate was significantly higher in the GTF group compared with the HG group (27.2% vs 6.6%, respectively; χ² = 12.462; P = .001). At the 3-month follow-up, the degree of ankle dorsiflexion was significantly higher in the HG group than in the GTF group (t = 3.144; P = .004). At 6-month and 1-year follow-up, no significant differences in ankle function were seen between the 2 groups.

Conclusion:

Hamstring tendon graft is associated with better early recovery of dorsiflexion compared with GTF. The long-term clinical outcomes of these 2 procedures are similar.

Strength Measurement After Achilles Tendon Repair

The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.

Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears

BACKGROUND

Rupture of the Achilles tendon (AT) is frequent in young recreational athletes. Conservative management, open surgery and percutaneous/minimally invasive approaches are all advocated, and conflicting data are available. This study compared functional and anthropometric outcomes of patients who underwent open or percutaneous repair.

METHODS

A retrospective comparative study, in which 38 patients underwent open and percutaneous techniques to manage AT ruptures. For functional assessment, the calf circumference of both injured and uninjured legs was evaluated. Isokinetic testing included total plantar flexion work, peak plantar flexion torque, total dorsiflexion work peak and dorsiflexion torque. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) were evaluated at a final minimum follow-up of 12months.

RESULTS

No major complications were observed. The average time to return to sport was 9months. AOFAS and ATRS values did not differ statistically between groups. Isokinetic variables and circumference were similar in the operated and non-operated limb in both groups, and did not differ either when comparing open and percutaneous repair.

CONCLUSIONS

Open and percutaneous repair of a torn Achilles tendon produced similar functional outcomes.

Tendon allograft for treatment of chronic Achilles tendon rupture: A systematic review

BACKGROUND

To summarize available evidence and determine if tendon allograft is an effective treatment for chronic Achilles tendon rupture.

METHODS

A search was performed in the PubMed, Web of Science, Embase and Cochrane Database from 1960 to April 2017 to identify relevant articles. Predefined inclusion and exclusion criteria were applied to identify all eligible articles.

RESULTS

Total 186 articles were identified through our systematic search. Of these, 9 publications met the inclusion criteria. Five studies were case reports; three were case series; and one were expert opinion. Of a total 35 patients, 34 underwent Achilles tendon allograft repair and 1 peroneus brevis tendon allograft reconstruction. All patients experienced good clinical and functional results, but most reports used non-validated outcome measures.

CONCLUSIONS

The evidence suggests that tendon allograft offers favorable outcomes in patients with chronic Achilles tendon rupture. However, randomized controlled trials which use validated functional outcome measures are required to determine effectiveness of this intervention.

LEVEL OF EVIDENCE

Level V, systematic review of Level IV and V studies.

Gracilis musculotendinous free flap for lower extremity reconstruction after surgical removal of malignant tumors: A report of five cases

BACKGROUND

Lower extremity reconstruction is challenging because of the need to restore form and function. Despite the many options for soft-tissue coverage, little research has addressed combined tendon and soft-tissue reconstitution. We present a series of patients undergoing lower extremity tendon reconstruction and wound coverage with a single free gracilis flap and its tendon.

METHODS

We studied five patients (age range, 51-81 years) undergoing lower limb reconstruction for defects involving soft tissue and tendon between 1998 and 2016 in the senior author's practice. Wounds (all in the foot and ankle region) were caused by sarcoma (n = 4) and Merkel cell carcinoma (n = 1) and ranged from 6.5-10 × 8-12 cm. Donor tendons, 2-18 cm long, were used to reconstruct the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and extensor retinaculum. Patient characteristics and outcomes were reviewed retrospectively.

RESULTS

Reconstructions used a gracilis muscle free flap and its tendon. Flap sizes ranged 5-6.5 × 11-14 cm. Complications were one case of cellulitis and one case of reoperation for flap thinning and tenolysis. All patients had at least 7 months of follow-up (mean: 37 months; range: 7-104 months). At latest follow-up, all patients were ambulatory. On average, patients resumed assisted ambulation 27 days postoperatively and unassisted ambulation 62 days postoperatively.

CONCLUSIONS

For complex wounds with soft-tissue and tendinous defects, the gracilis muscle free flap may be a reconstructive option. We recommend it be considered as a single-donor incision option for lower extremity reconstruction.

Chronic Achilles Ruptures: Reconstructive Options

Achilles tendon ruptures, if neglected or identified late, lead to impairments in function and gait. Surgical reconstruction is typically required to restore the resting length and tension to the gastrocnemius-soleus complex. A variety of reconstructive options have been described, depending on several factors, including chronicity, residual gap size, remaining tissue quality and vascularity, location of tendon rupture or deficiency, and patient-specific factors. Despite the many surgical options described from local soft-tissue rearrangements and tendon transfers, to the use of allograft tissue and synthetic material augmentation, there is understandably a paucity of evidence-based guidelines available to direct surgeons in the optimal procedure for each patient-specific situation. Reconstructive options for the patient with a chronic Achilles rupture are detailed and reviewed here, to serve as a framework for the treating surgeon in these complex cases.

Surgical management of chronic Achilles tendon ruptures using less invasive techniques

BACKGROUND

Surgical management of chronic Tendo Achillis (TA) ruptures usually requires tendon grafting procedures. Several techniques have been described. We examined the outcome of three different less invasive (incisions length less than 3 cm) tendon transfer techniques in the management of patients with a chronic rupture of the TA.

METHODS

Of 62 patients (39 males and 23 females; mean age 44.8 years; range 29.3-62 years) with chronic TA ruptures managed operatively, 21 patients had a ≥6cm gap and underwent free ipsilateral semitendinosus (ST) graft (21 patients), whereas patients with smaller gaps had either ipsilateral peroneus brevis (PB) (20 patients) or ipsilateral flexor hallucis longus (FHL) transfer (21 patients). Outcome measures included maximum calf circumference, isometric plantar flexion strength, and the Achilles tendon total rupture score (ATRS), preoperatively and at the last follow up. We also recorded the time to return to activities of daily living (ADL) and sports, and the number of single-leg heel lifts on the affected leg at the last follow up, at an average of 35.4 months.

RESULTS

Patient characteristics between groups were similar. All outcome measures significantly improved after surgery (p<0.001), without differences between the three groups. Return to ADL was possible at an average of 4.5 months. Patients undergoing PB transfer had a slower return to sports compared to the other groups, at 6.9±0.5months versus 6.1±0.8 for the FHL and 5.8±0.6 for the ST groups (t-test p=0.005 and p<0.001, respectively). However, 13/14 patients (90%) in the PB group returned to high impact sports, compared to 9/12 (75%) in the FHL and 6/11 (55%) in the ST groups (Fisher's test, p=0.31 and p=0.056, respectively).

CONCLUSION

All three techniques produced significant functional improvement, and return to sports was possible in most patients. This study does not demonstrate a clear advantage of one technique over the others.

Surgical reconstruction of the fascia lata and posterior tibial artery perforator flap to treat children with simultaneous injury to the Achilles tendon and heel skin

Children with simultaneous injury to the Achilles tendon and heel skin remain a challenge for clinicians. The purpose of this study is to evaluate a combined surgical procedure involving use of the fascia lata to reconstruct the Achilles tendon, and the posterior tibial artery perforator flap to cover the accompanying heel skin injury.Between February 2010 and February 2013, 8 children (3 females and 5 males) between 3 and 12 years of age, with a median age of 7.5 years, were hospitalized in the First Affiliated Hospital of Shantou University Medical College. All injuries involved damage to an Achilles tendon and heel skin. In all patients, the fascia lata was transplanted to reconstruct the Achilles tendon and the posterior tibial artery perforator flap transplanted to cover the skin injury.Hospitalization was 11 to 15 days (mean 13.5 days). Local necrosis (15% of the area) occurred in 1 flap, but healed after changing dressing. All other flaps survived well. At follow-up after 1 to 2 years, all children had recovered good plantar-flexion and supported their weight while walking. Use of the Arner-Lindholm standard to rate clinical efficacy revealed that of the 8 cases, 6 cases showed excellent recovery and 2 were good, with 0 cases ranking moderate or poor. The excellent and good rate was 100%.Child patients with Achilles tendon injury accompanied by heel skin injury are still a challenge for clinicians. Use of the fascia lata, combined with a posterior tibial artery perforator flap, to reconstruct the Achilles tendon and heel skin for children is a feasible, safe, effective method, faster than other methods for recovery, and should be widely applied in the clinic.

The Missed Achilles Tear: Now what?

Chronic Achilles tendon ruptures are debilitating injuries and are often associated with large tendon gaps that can be challenging for the foot and ankle surgeon to treat. Preoperative evaluation should include the patient's functional goals, medical comorbidities, MRI assessment of gastrocsoleus muscle viability, condition of adjacent flexor tendons, and size of the tendon defect. Although several surgical techniques have been described, the surgeon must formulate an individualized treatment plan for the patient. This article reviews the principles of diagnosis, treatment options, and clinical outcomes, and outlines the authors' preferred techniques.

Chronic Achilles Tendon Rupture

Background:

The Achilles tendon, the largest and strongest tendon in the human body, is nevertheless one of the tendons which most commonly undergoes a complete subcutaneous tear. Achilles tendon ruptures are especially common in middle aged men who occasionally participate in sport. Even though Achilles tendon ruptures are frequent, up to 25% of acute injuries are misdiagnosed, and present as chronic injuries.

Methods:

This is a review article about diagnosis and management of chronic Achilles tendon ruptures. Minimally invasive Achilles tendon reconstruction is discussed.

Results:

The optimal surgical procedure is still debated, however, less invasive peroneus brevis reconstruction technique and free hamstring autograft provide good functional results.

Conclusion:

The management of chronic ruptures is more demanding than acute tears, because of the retraction of the tendon ends, and the gap makes primary repair impossible. Wound complications and infections are frequent after open procedures. Minimally invasive treatments provide good functional results and lower complications rate.

[Curative analysis of individual surgery for chronic Achilles tendon rupture]

Objective

To investigate the effectiveness of individual surgery for chronic Achilles tendon rupture.

Methods

A retrospective analysis was made on the clinical data of 25 patients (26 Achilles tendons) with chronic Achilles tendon rupture between September 2009 and March 2016, including 22 males and 3 females with a mean age of 38 years (range,18-59 years). The median disease duration was 12 weeks (range, 4 weeks to 12 years). The repairing method depended on the defect size, injury site, and tissue condition of the involved Achilles tendon: 9 Achilles tendons were repaired by end-to-end anastomosis, 8 by a gastrocnemius turndown flap, and 9 by auto free tendon (4 ipsilateral hamstring tendon and 5 ipsilateral 2/3 peroneus longus tendon). The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, heel lifting of the affected leg, active ankle range of motion (plantar flexion and dorsiflexion), maximum calf circumference, and complications were applied to assess the effectiveness.

Results

Hypersensitivity occurred in 1 incision, and stage I healing was obtained in the other incisions. No complication of re-rupture, infection, nerve injury, or deep venous thrombosis occurred. All the patients were followed up 8-85 months (mean, 34 months). The AOFAS ankle-hind foot score was significantly improved to 95.81±5.34 at last follow-up from preoperative 50.54±5.52 ( t=-34.844, P=0.000); the excellent and good rate was 100% (excellent in 21 cases and good in 4 cases). The active dorsiflexion of the operated side [(13.9±2.4)°] was significantly lower than that of normal side [(16.7±2.0)°] ( t=-9.099, P=0.000), but the active plantar flexion showed no significant difference between affected side [(39.8± 3.2)°] and normal side [(40.6±2.6°)] ( t=-1.917, P=0.068). The maximum calf circumference of the operated side [(379.4±18.8) mm] was significantly lower than that of normal side [(387.1±16.6) cm] ( t=-5.053, P=0.000). The other patients could finish heel lifting of the affected leg without limitation except for 1 patient. All patients returned to normal work and activity, and 12 patients returned to normal sports.

Conclusion

Individual surgery depending on the defect, injury site, and tissue condition of the involved Achilles tendon can repair all kinds of chronic Achilles tendon rupture with a low rate of complications.

Surgical Strategy for the Chronic Achilles Tendon Rupture

Background. Chronic Achilles tendon rupture is usually misdiagnosed and treated improperly. This study aims to better understand the treatment of chronic Achilles tendon rupture. Methods. Patients who were not able to perform a single-limb heel rise were chosen. Pre- and postoperative magnetic resonance imaging (MRI) were conducted. By evaluating the presence or absence of Achilles tendon stumps and the gap length of rupture, V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer were selected for tendon repair. The function of ankle and foot was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and Achilles Tendon Total Rupture Score (ATRS). Results. Twenty-nine patients were followed up. One patient had superficial incision infection, which was healed after debridement and oral antibiotics. Three months postoperatively, MRI showed some signs of inflammation, which disappeared at one or two years postoperatively. All patients were able to perform a single-limb heel rise. Mean AOFAS scores and ATRS scores were increased at the latest follow-up. Conclusion. Surgical options can be determined by evaluating the presence of the Achilles tendon stumps and the gap length, which can avoid using the nearby tendon and yield satisfactory functional results.

Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps

BACKGROUND

Several surgical procedures for chronically ruptured Achilles tendons have been reported. Resection of the interposed scar tissue located between the tendon stumps and reconstruction using normal autologous tissue have been well described. We developed a direct repair procedure that uses scar tissue, which obviates the need to use normal autologous tissue.

METHODS

Thirty consecutive patients with Achilles tendon ruptures with a delay in diagnosis of >4 weeks underwent removal of a section of scar and healing tissue with direct primary suture of the ends of the tendon without the use of allograft or autograft. Patients were followed for a mean time of 33 months. Preoperative and postoperative clinical outcomes were measured with the Achilles Tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. In addition, the patients underwent preoperative and postoperative functional measurements and magnetic resonance imaging. Lastly, we evaluated the histology of the interposed healing tissue.

RESULTS

The mean AOFAS scores were 82.8 points preoperatively and 98.1 points postoperatively. The mean postoperative ATRS was 92.0 points. At the time of the latest follow-up, none of the patients had experienced tendon reruptures or difficulties in walking or climbing stairs, and all except 2 patients could perform a single-limb heel rise. All athletes had returned to their pre-injury level of sports participation. Preoperative T2-weighted magnetic resonance imaging showed that 22 Achilles tendons were thickened with diffuse intratendinous high-signal alterations, and 8 Achilles tendons were thinned. Postoperative T2-weighted magnetic resonance imaging findings included fusiform-shaped tendon thickening and homogeneous low-signal alterations of the tendons in all patients. Histologically, the interposed scar tissue consisted of dense collagen fibers.

CONCLUSIONS

Shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for treatment-delayed or neglected Achilles tendon rupture.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization

Background

Plantaris tendon, peronus brevis tendon and flexor hallucis longus tendon augmentation, commonly used in Achilles tendon rupture, often lead to weakening of injured foot and they require the immobilization after the surgery. It is essential to develop the technique, which gives no such limitation and allows for immediate functional improvement.

Methods

We present our method of minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization.

Results

Posterolateral and posteromedial portals were made approximately 3 cm above the posterosuperior part of the calcaneus to clean the area of the Achilles tendon endoscopically. Then the hamstrings are harvested and prepared for the “Endobutton” system. A midline incision of the skin is performed approximately 1 cm above the posterosuperior part of the calcaneus to approach to the posterosuperior part of the calcaneus. Then under fluoroscopy the calcaneus was drilled through using K-wire. The distal end of the graft equipped with an Endobutton loop was entered into the drilled tunnel in the calcaneus. Later, 8 consecutive skin incisions are performed. Proximal ends of the graft were brought out through the native Achilles tendon reaching medial and lateral skin incisions. The final step was to transfer and tie the graft ends through the most proximal skin incision.

Conclusions

This minimally invasive, endoscopic technique allows reconstruction of the Achilles tendon using semitendinosus and gracilis tendons with Endobutton stabilization and can be used in so-called “difficult”, resistant cases as a “salvage procedure”.

Biomechanical comparison of three methods for distal Achilles tendon reconstruction

PURPOSE

To compare the load at failure and stiffness associated with three surgical techniques for distal Achilles tendon reconstruction (AT).

METHODS

Nine matched pairs of fresh-frozen human cadaveric ATs were divided into three groups. Distal AT reconstruction was performed using suture anchors or one of two lengths of tendon overlap (10 or 5 mm). Each tendon was loaded to failure. The load at failure (N), stiffness (N/mm), and mode of failure were recorded. Differences in load at failure and stiffness were analysed.

RESULTS

Mean load at failure was significantly higher in the 10-mm group than in the 5-mm group (p < 0.05) or the suture-anchor group (p < 0.05). Load at failure did not differ significantly between the suture-anchor and 5-mm group, and stiffness did not differ significantly between any two groups. In the 10- and 5-mm groups, failure was caused by the grafts pulling out through the substance of the AT. Modes of failure varied in the suture-anchor group.

CONCLUSIONS

The load at failure was higher in the 10-mm group than in the 5-mm and suture-anchor groups. Although all three surgical techniques provide sufficient primary load-bearing ability, the 10-mm tendon-overlap technique may be more conducive to early post-operative rehabilitation.

Successful treatment of a fracture of a huge Achilles tendon ossification with autologous hamstring tendon graft and gastrocnemius fascia flap: a case report

Background

Fracture of an ossified Achilles tendon is a rare entity, and no standard treatment has been established. This is the first report to describe the use of a hamstring tendon graft and gastrocnemius fascia flap for Achilles tendon reconstruction.

Case presentation

We present the case of a 50-year-old woman with fracture of an ossified Achilles tendon. She presented to our clinic with acute right hindfoot pain, which started suddenly while going up the stairs. Plain radiography and magnetic resonance imaging revealed a massive ossification on the right Achilles tendon extending over 14 cm in length; the ossification was fractured at 5 cm proximal to the calcaneus insertion. Surgical treatment included removal of the ossified tendon and reconstruction with an autologous hamstring tendon graft and gastrocnemius fascia flap. One year after surgery, she was able to walk with little pain or discomfort and to stand on her right tiptoe.

Conclusion

Our novel surgical procedure may be useful in the treatment of fractured ossified Achilles tendons and large Achilles tendon defects.

Reconstruction of defects involving the Achilles tendon and local soft tissues

A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7).

At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (sd 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (sd 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction.

These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction.

Cite this article: Bone Joint J 2015;97-B:215–20.

Endoscopic-assisted achilles tendon reconstruction with free hamstring tendon autograft for chronic rupture of achilles tendon: clinical and isokinetic evaluation

PURPOSE

To evaluate the clinical and functional outcome of endoscopic-assisted reconstruction of chronic ruptures of the Achilles tendon using free hamstring tendon autograft.

METHODS

We present a case series of 15 patients who had chronic ruptures of the Achilles tendon (>6 weeks earlier) and underwent endoscopic-assisted reconstruction with a free hamstring autograft. The graft loop was passed through and fixed to the proximal stump of the tendon. The graft was then passed through suture to the distal stump and finally inserted into a tunnel in the anterior calcaneus to the Achilles tendon insertion and fixed with an bioabsorbable interference screw. The mean follow-up period was 27 months (SD, 3 months; range, 24 to 33 months). All patients underwent magnetic resonance imaging preoperatively, immediately postoperatively, and at follow-up 2 years postoperatively. All patients were functionally evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot preoperatively and postoperatively. Calf muscle power was evaluated by isokinetic strength testing at 2 years' follow-up.

RESULTS

The mean size of the gap on preoperative magnetic resonance imaging was 49 mm (SD, 9 mm). The mean preoperative AOFAS score was 32.6 (SD, 7.5). There was a statistically significant improvement in the postoperative AOFAS score after 2 years to 90.8 (SD, 3.54) (P < .05). The mean time of return to all daily activities (except running and other sports) was 12.6 weeks (SD, 1.39 weeks). Isokinetic testing showed a nonsignificant deficit (<10%) between the involved and uninvolved plantar flexors and dorsiflexors with regard to peak torque, average power, and total work.

CONCLUSIONS

Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft for chronic ruptures of the Achilles tendon showed good to excellent results in all patients. Isokinetic testing showed a nonsignificant deficit between the involved and uninvolved sides at 2 years' follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic cases series.

In vitro characterization of a novel tissue engineered based hybridized nano and micro structured collagen implant and its in vivo role on tenoinduction, tenoconduction, tenogenesis and tenointegration

Surgical reconstruction of large tendon defects is technically demanding. Tissue engineering is a new option. We produced a novel tissue engineered, collagen based, bioimplant and in vitro characterizations of the implant were investigated. In addition, we investigated role of the collagen implant on the healing of a large tendon defect model in rabbits. A two cm length of the left rabbit's Achilles tendon was transected and discarded. The injured tendons of all the rabbits were repaired by Kessler pattern to create and maintain a 2 cm tendon gap. The collagen implant was inserted in the tendon defect of the treatment group (n = 30). The defect area was left intact in the control group (n = 30). The animals were euthanized at 60 days post injury (DPI) and the macro- micro- and nano- morphologies and the biomechanical characteristics of the tendon samples were studied. Differences of P < 0.05 were considered significant. The host graft interaction was followed at various stages of tendon healing, using pilot animals. At 60 DPI, a significant increase in number, diameter and density of the collagen fibrils, number and maturity of tenoblasts and tenocytes, alignment of the collagen fibrils and maturity of the elastic fibers were seen in the treated tendons when compared to the control ones (P < 0.05). Compared to the control lesions, number of inflammatory cells, amount of peritendinous adhesions and muscle fibrosis and atrophy, were significantly lower in the treated lesions (P < 0.05). Treatment also significantly increased load to failure, tensile strength and elastic modulus of the samples as compared with the control ones. The collagen implant properly incorporated with the healing tissue and was replaced by the new tendinous structure which was superior both ultra-structurally and physically than the loose areolar connective tissue regenerated in the control lesions. The results of this study may be valuable in the clinical practice.

Tendon transfers in the treatment of Achilles' tendon disorders

The Achilles tendon is the strongest tendon in the human body and, as such, has its share of problems. Although many conditions affecting this tendon can be treated nonoperatively, surgical intervention is often necessary. Local, regional, distant, and allograft tendon can be used to supplement or enhance reconstruction or repair of the Achilles tendon. Specific techniques are explored and described and the published results from the literature summarized. This article explores the use of tendon transfers and supplementation in the treatment of insertional and noninsertional Achilles tendinosis as well as in cases of neglected or chronic ruptures of the tendoachilles.

Can foot compression under a plaster cast prevent deep-vein thrombosis during lower limb immobilisation?

We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (ϕ = 0.71; p = 0.019), leading to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application.

Implantation of a novel biologic and hybridized tissue engineered bioimplant in large tendon defect: an in vivo investigation

Surgical reconstruction of large Achilles tendon defects is technically demanding. There is no standard method, and tissue engineering may be a valuable option. We investigated the effects of 3D collagen and collagen-polydioxanone sheath (PDS) implants on a large tendon defect model in rabbits. Ninety rabbits were divided into three groups: control, collagen, and collagen-PDS. In all groups, 2 cm of the left Achilles tendon were excised and discarded. A modified Kessler suture was applied to all injured tendons to retain the gap length. The control group received no graft, the treated groups were repaired using the collagen only or the collagen-PDS prostheses. The bioelectrical characteristics of the injured areas were measured at weekly intervals. The animals were euthanized at 60 days after the procedure. Gross, histopathological and ultrastructural morphology and biophysical characteristics of the injured and intact tendons were investigated. Another 90 pilot animals were also used to investigate the inflammatory response and mechanism of graft incorporation during tendon healing. The control tendons showed severe hyperemia and peritendinous adhesion, and the gastrocnemius muscle of the control animals showed severe atrophy and fibrosis, with a loose areolar connective tissue filling the injured area. The tendons receiving either collagen or collagen-PDS implants showed lower amounts of peritendinous adhesion, hyperemia and muscle atrophy, and a dense tendon filled the defect area. Compared to the control tendons, application of collagen and collagen-PDS implants significantly improved water uptake, water delivery, direct transitional electrical current and tissue resistance to direct transitional electrical current. Compared to the control tendons, both prostheses showed significantly increased diameter, density and alignment of the collagen fibrils and maturity of the tenoblasts at ultrastructure level. Both prostheses influenced favorably tendon healing compared to the control tendons, with no significant differences between collagen and collagen-PDS groups. Implantation of the 3D collagen and collagen-PDS implants accelerated the production of a new tendon in the defect area, and may become a valuable option in clinical practice.

Tendon tissue engineering and its role on healing of the experimentally induced large tendon defect model in rabbits: a comprehensive in vivo study

Healing of large tendon defects is challenging. We studied the role of collagen implant with or without polydioxanone (PDS) sheath on the healing of a large Achilles tendon defect model, in rabbits. Sixty rabbits were divided into three groups. A 2 cm gap was created in the left Achilles tendon of all rabbits. In the control lesions, no implant was used. The other two groups were reconstructed by collagen and collagen-PDS implants respectively. The animals were clinically examined at weekly intervals and their lesions were observed by ultrasonography. Blood samples were obtained from the animals and were assessed for hematological analysis and determination of serum PDGF level, at 60 days post injury (DPI). The animals were then euthanized and their lesions were assessed for gross and histopathology, scanning electron microscopy, biomechanical testing, dry matter and hydroxyproline content. Another 65 pilot animals were also studied grossly and histopathologically to define the host implant interaction and graft incorporation at serial time points. The treated animals gained significantly better clinical scoring compared to the controls. Treatment with collagen and collagen-PDS implants significantly increased the biomechanical properties of the lesions compared to the control tendons at 60DPI (P<0.05). The tissue engineered implants also reduced peritendinous adhesion, muscle fibrosis and atrophy, and increased ultrasonographical echogenicity and homogenicity, maturation and differentiation of the collagen fibrils and fibers, tissue alignment and volume of the regenerated tissue compared to those of the control lesions (P<0.05). The implants were gradually absorbed and substituted by the new tendon. Implantation of the bioimplants had a significant role in initiating tendon healing and the implants were biocompatible, biodegradable and safe for application in tendon reconstructive surgery. The results of the present study may be valuable in clinical practice.

Role of tissue-engineered artificial tendon in healing of a large Achilles tendon defect model in rabbits

BACKGROUND

Treatment of large Achilles tendon defects is technically demanding. Tissue engineering is an option. We constructed a collagen-based artificial tendon, covered it with a polydioxanon (PDS) sheath, and studied the role of this bioimplant on experimental tendon healing in vivo.

STUDY DESIGN

A 2-cm tendon gap was created in the left Achilles tendon of rabbits (n = 120). The animals were randomly divided into 3 groups: control (no implant), treated with tridimensional-collagen, and treated with tridimensional-collagen-bidimensional-PDS implants. Each group was divided into 2 subgroups of 60 and 120 days postinjury (DPI). Another 50 pilot animals were used to study the host-implant interaction. Physical activity of the animals was scored and ultrasonographic and bioelectrical characteristics of the injured tendons were investigated weekly. After euthanasia, macro, micro, and nano morphologies and biophysical and biomechanical characteristics of the healing tendons were studied.

RESULTS

Treatment improved function of the animals, time dependently. At 60 and 120 DPI, the treated tendons showed significantly higher maximum load, yield, stiffness, stress, and modulus of elasticity compared with controls. The collagen implant induced inflammation and absorbed the migrating fibroblasts in the defect area. By its unique architecture, it aligned the fibroblasts and guided their proliferation and collagen deposition along the stress line of the tendon and resulted in improved collagen density, micro-amp, micro-ohm, water uptake, and delivery of the regenerated tissue. The PDS-sheath covering amplified these characteristics. The implants were gradually absorbed and replaced by a new tendon. Minimum amounts of peritendinous adhesion, muscle atrophy, and fibrosis were observed in the treated groups. Some remnants of the implants were preserved and accepted as a part of the new tendon.

CONCLUSIONS

The implants were cytocompatible, biocompatible, biodegradable, and effective in tendon healing and regeneration. This implant may be a valuable option in clinical practice.