Using a Posterior Compartment Fasciotomy and Paratenon Closure in Acute Achilles Tendon Repair

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.

Diffuse-Type Giant Cell Tumor of the Paratenon of Achilles Tendon Requiring Reconstruction Using Bilateral Autografts: A Case Report

Although a diffuse-type giant cell tumor is a rare benign lesion, when it develops it tends to localize to the tendons of the hand and foot. In this study, we report the case of a 41-year-old male patient who was diagnosed with diffuse-type paratenon giant cell tumor involving the Achilles tendon. The duration of the bilateral tumors was 8 years. He visited first affiliated Hospital of Wenzhou Medical University for medical attention. Both his Achilles tendons required removal. The reconstructed Achilles tendon was replaced using tissue derived from the knee and foot. Postoperatively, the patient recovered well and regained full range of motion in the ankle. The use of autografts may shorten patients' recovery period.

Repair within the first 48 h in the treatment of acute Achilles tendon ruptures achieves the best biomechanical and histological outcomes

PURPOSE

To compare the biomechanical and histological properties of Achilles tendons repaired at different time points during the acute injury period.

METHODS

Thirty-six skeletally mature Sprague-Dawley rats underwent bilateral mid-substance Achilles tenotomy. The Achilles tendons were repaired either in the first 24 h (group 1), 24-48 h (group 2), 48-72 h (group 3), or > 72 h (mean: 120 ± 5.2 h) (group 4) after tenotomy. Six weeks after repair, nine tendons per group were assessed biomechanically and histologically. The Stoll histological scoring system was used for histological examination. The groups were compared with each other and native tendons (control group). The correlations between biomechanical and histological results were analysed.

RESULTS

There were no significant differences between groups 1, 2 and 3 regarding the mean load to failure; it was significantly lower in group 4. Healed tendons in groups 1, 2 and 3 had significantly greater stiffness than native tendons and group 4 tendons. All healed tendons had a larger cross-sectional area than native tendons. There was no significant difference in tendon length between the groups. There was no significant difference in Young's modulus between the groups; Young's modulus was lower in all the groups than in the control group. Group 1 had significantly higher extracellular matrix organization, cell alignment, cell distribution and nucleus morphology scores and total scores than group 4. Group 1 had significantly higher extracellular matrix organization, cell distribution, vascularization and inflammation scores and total scores than group 3. A significant positive correlation was detected between the maximum load to failure and total histological score.

CONCLUSION

Repair of acute Achilles tendon rupture within 48 h, and especially in the first 24 h, provides better biomechanical and histological outcomes. In the clinical practice, the data could be used to decrease re-rupture rates, to achieve more anatomical tendon healing and to implement more effective post-operative rehabilitation programme.

Reconstruction of Complicated Achilles Tendon Ruptures with Soft Tissue Defects - a Systematic Overview and Development of a Treatment Algorithm

Achilles tendon ruptures are among the most common ruptures of large tendons. Due to the vulnerable soft tissue there is a high risk of soft tissue defects. The combination of Achilles tendon ruptures and soft-tissue defects remains a challenge for the surgeon. Despite different treatment options there is a lack of structured treatment recommendation. By means of a systematic literature review and experience from our own clinic standard, an overview of the stepwise treatment options is presented. A treatment algorithm for reconstructive measures of Achilles tendon ruptures accompanied by soft-tissue defects according to the length of defect of the Achilles tendon, the size of the soft-tissue defect and patient-individual factors is developed. This is intended to serve the surgeon as a basis for decision making prior to application of therapy.

Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review

BACKGROUND

Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines.

PURPOSE

To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture.

RESULTS

A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53).

CONCLUSION

Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.

Open Re-rupture of the Achilles Tendon Following Minimally Invasive Repair: A Case Report

In this report, we describe a rare complication of an open re-rupture of the Achilles tendon following a minimally invasive Achilles tendon repair on a healthy 29-year-old active male. The reinjury happened 19 weeks following the primary surgical repair of a spontaneous rupture, performed by minimally invasive technique with the help of a jig using partially absorbable sutures and four locking stitches. The wound of the open re-rupture was transverse, in a perpendicular orientation relative to the longitudinal approach used in the index procedure. Increased scar tissue formation, the absence of an adequate layer of paratenon overlying the primary tendon repair, and foreign-body reaction to the suture may have been involved in the occurrence of this unusual complication in the surgical treatment of Achilles tendon rupture.

Response of the Injured Tendon to Growth Factors in the Presence or Absence of the Paratenon

BACKGROUND

The paratenon is important for Achilles tendon healing. There is much interest in the use of exogenous growth factors (GFs) as potential agents for accelerating the healing of damaged Achilles tendons.

PURPOSE/HYPOTHESIS

The present study used a rat model to study the responses of the injured Achilles tendon to GFs in the presence or absence of the paratenon. The hypothesis was that responses of the injured tendon to GFs would be lower in the absence of a paratenon.

STUDY DESIGN

Controlled laboratory study.

METHODS

A 4-mm defect was created in the right Achilles tendon of 60 skeletally mature rats, which were treated with a validated combination of GFs (bFGF, BMP-12, and TGF-β1). Animals were randomly assigned to the intact paratenon (IP) group or resected paratenon (RP) group. Healing was studied anatomically, mechanically, and histologically after 1, 2, and 4 weeks.

RESULTS

IP tendons showed improved healing compared with RP tendons. IP tendons were significantly stronger (32.2 N and 48.9 N, respectively) than RP tendons (20.1 N and 31.1 N, respectively) after 1 and 2 weeks. IP tendons did not elongate as much as RP tendons and had greater cross-sectional areas (18.0 mm², 14.4 mm², and 16.4 mm², respectively) after 1, 2, and 4 weeks compared with RP tendons (10.5 mm², 8.4 mm², and 11.9 mm², respectively). On histology, earlier collagen deposition and parallel orientation of fibrils were found for IP tendons.

CONCLUSION

The paratenon is essential for efficient Achilles tendon healing. Healing with GFs in this Achilles tendon defect model was superior in the presence of the paratenon.

CLINICAL RELEVANCE

Biological approaches to tendon engineering using GFs are in vogue and have been shown to improve healing of the rat Achilles tendon, most likely by inducing progenitor cells located within the paratenon. Clinically, resection or incision of the paratenon has been proposed for wound closure. Our data demonstrate the fundamental importance of the paratenon, which therefore should be preserved during Achilles tendon repair, especially if augmented with products such as platelet-rich plasma or autologous conditioned serum that are rich in GFs.

The Role of the Paratenon in Achilles Tendon Healing: A Study in Rats

BACKGROUND

The role of the paratenon in tendon healing is unknown. The present study compares healing in the presence or absence of the paratenon in an Achilles tendon defect model in rats.

HYPOTHESIS

Resection of the paratenon impairs tendon healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixty skeletally mature Sprague Dawley rats were randomly assigned to either a resected paratenon (RP) group or an intact paratenon (IP) group. In all animals, a 4-mm portion of the Achilles tendon was resected in the midsubstance. In the RP group, the paratenon was resected completely. In the IP group, the paratenon was opened longitudinally and closed again after the tendon defect had been created. One, 2, and 4 weeks after surgery, 7 animals per group were tested biomechanically and 3 animals per group examined histologically.

RESULTS

The recovery of mechanical strength was much more rapid in IP tendons. Tear resistance was significantly increased for IP tendons (41.3 ± 8.8 N and 47.3 ± 14.1 N, respectively) compared with RP tendons (19.3 ± 9.1 N and 33.2 ± 6.4 N, respectively) after 1 and 2 weeks. The cross-sectional area was larger in the IP group after 1 and 2 weeks (8.2 ± 2.3 mm² and 11.3 ± 3.1 mm² vs 5.0 ± 2.4 mm² and 5.9 ± 2.0 mm², respectively) compared with the RP group. Tendon stiffness was greater in the IP group after 1 week (10.4 ± 1.9 N/mm vs 4.5 ± 1.6 N/mm, respectively) compared with the RP group. In comparison, normal contralateral tendons had a maximal tear resistance of 56.6 ± 7.2 N, a cross-sectional area of 3.6 ± 0.7 mm², and stiffness of 17.3 ± 3.8 N/mm. Hematoxylin and eosin staining revealed slightly delayed healing of RP tendons. Early collagen formation was seen in the IP group already after 1 week, whereas in the RP group, this only occurred after 2 weeks. After 4 weeks, the IP tendons showed more collagen crimp formation than the RP tendons.

CONCLUSION

An intact paratenon promotes healing of the Achilles tendon.

CLINICAL RELEVANCE

Although incision or resection of the paratenon has been advocated when repairing injured or degenerative tendons, our data suggest that the integrity of the paratenon should be preserved.