Percutaneous Achilles tendon repair with the Dresden instrument. Clinical and MRI evaluation of 90 patients

BackgroundThis study aims at evaluating a substantial number of patients treated with a percutaneous, paratenon preserving technique for Achilles tendon repair using three different incisions with clinical follow-up and magnetic resonance imaging (MRI).MethodsNinety patients with percutaneous Achilles tendon repair using the Dresden technique for acute rupture were evaluated. Fifteen patients were treated using a central approach, 15 patients using a posterolateral approach and the original posteromedial approach was used in 60 patients. All patients were followed clinically and with MRI after 1 and 6 months post-operatively.ResultsUsing the standard posteromedial approach no complications were seen. With the central approach 4 (27%) wound healing problems were observed and with the posterolateral approach 2 (13%) sural nerve lesions occurred. One patient (1.1%) had a rerupture. MRI revealed an increased diameter at the rupture site and distal to it as well as an increasingly homogeneous signal over time.ConclusionsPercutaneous Achilles tendon repair with the Dresden technique yields excellent clinical results and a low complication rate. Modification of the original incision is discouraged.     

Prospective randomized clinical trial of aggressive rehabilitation after acute Achilles tendon ruptures repaired with Dresden technique

BackgroundRupture of the Achilles tendon is a common injury during working years. Aggressive rehabilitation may provide better outcomes, but also a greater chance of re-rupture.ObjectiveTo determine if aggressive rehabilitation has better clinical outcomes for Achilles tendon function, Triceps surae function, one-leg heel rise capacity and lower complication rate during twelve weeks after percutaneous Achilles tendon repair compared to conventional rehabilitation.DesignRandomized controlled trial.MethodThirty-nine patients were prospectively randomized. The aggressive group (n = 20, 41.4 ± 8.3 years) received rehabilitation from the first day after surgery. The conventional group (n = 19, 41.7 ± 10.7 years) rested for 28 days, before rehabilitation started. The statistical parameters were the Achilles tendon rupture score (ATRS), verbal pain scale, time to return to work, pain medication consumption, Achilles tendon strength, dorsiflexion range of motion (RoM), injured-leg calf circumference, calf circumference difference, one-leg heel rise repetition and difference, re-rupture rate, strength deficit rate, and other complication rates. Mixed-ANOVA and Bonferroni's post hoc test were performed for multiple comparisons. Student's t-test was performed for parameters measured on the 12th week.ResultsThe aggressive group with respect to the conventional group had a higher ATRS; lower verbal pain score; lower pain medication consumption; early return to work; higher Achilles tendon strength; higher one-leg heel rise repetitions; and lower one-leg heel rise difference. The re-rupture rate was 5% and 5%, the strength deficit rate was 42% and 5%, and other complications rate was 11% and 15% in the conventional and aggressive group, respectively.ConclusionPatients with Dresden repair and aggressive rehabilitation have better clinical outcomes, Achilles tendon function and one-leg heel rise capacity without increasing the postoperative complications rate after 12 weeks compared to rehabilitation with immobilization and non-weight-bearing during the first 28 days after surgery.     

An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device

BackgroundPercutaneous Achilles tendon repairs are gaining in popularity. This study aims to quantify the risk of sural nerve injury when using the Achillon device.MethodsThe Achillon device was instrumented into 15 cadaveric specimens and through dissection the rate of sural nerve puncture and the position of the sural nerve in relation to the Achilles tendon was documented.ResultsThe sural nerve was found lateral to the Achilles tendon insertion point over a range of 14.3 mm and crossed the lateral border of the Achilles tendon over a range of 57.7 mm.The sural nerve was punctured a total of 6 times and in 4 out of 15 cadaveric specimens (27%). Four out of the 6 punctures occurred when the Achillon device was instrumented distally.ConclusionsThe sural nerve displays a highly variable anatomical course and there is a risk of puncture during percutaneous Achilles tendon repair using the Achillon device.     

A novel repair method for the treatment of acute Achilles tendon rupture with minimally invasive approach using button implant: A biomechanical study

BackgroundMinimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low rate of complications. However there are still controversies about optimal technique. In this study we aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair technique and evaluate its biomechanical properties comparing with native tendon and Krackow technique.Methods27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including native tendons. Unidirectional tensile loading to failure was performed at 25 mm/min. Biomechanicalproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and Young'smodulus (GPa) was measured for each group. All groups were compared with each other using one-wayANOVA followed by the Tukey HSD multiple comparison test (a = 0.05).ResultsThe average peak force (N) to failure of group 1 and group 2 and control group was 415.6 ± 57.6, 268.1 ± 65.2 and 704.5 ± 85.8, respectively. There was no statistically significant difference between native tendon and group 1 for the amount elongation at failure (p > 0.05).ConclusionsRegarding the results, we concluded that Endobutton-assisted modified Bunnell technique provides stronger fixation than conventional techniques. It may allow early range of motion and can be easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality tendon at the distal part of rupture.Level of evidenceLevel II, Biomechanical research study.     

Early rehabilitation after open repair for patients with a rupture of the Achilles tendon

PurposeAs outdoor activities participation increase, Achilles tendon rupture incidence also tends to increase. There are a number of treatment and rehabilitation options for a ruptured Achilles tendon. However, the optimal rehabilitation protocols are still under debate. The purpose of this study is to determine whether early rehabilitation is more effective than conventional rehabilitation.MethodsMedical records of 56 patients who had been treated with open repair after a ruptured Achilles tendon were retrospectively reviewed. 24 patients were treated postoperatively with below knee cast immobilization for four weeks, and they started tolerable weight-bearing rehabilitation at four weeks’ follow-up. The remaining 32 patients were managed postoperatively with short leg splint immobilization for two weeks and started the tolerable weight-bearing at two weeks’ follow-up. We evaluated the patients several times to identify when the single heel raise was possible and measured the American Orthopedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) as a functional outcome.ResultsThe single heel raise test was positive in all patients at the last assessment. But there were no statistically significant differences between the groups (p = 0.137). The patients in the Cast group took significantly more time to return to work than did the patients in the Splint group (p = 0.032). And AOFAS scores and ATRS were slightly higher in the Splint group than in the Cast group. There were statistically significant differences (p = 0.042, p = 0.028) between the two groups.ConclusionThe early rehabilitation did not lead to greater endurance, but it showed better results in the return to work and the Achilles functional score. Early rehabilitation after open repair for patients with a ruptured Achilles tendon is helpful for functional recovery.Type of study / Level of evidence: Therapeutic, Level III.     

Chronic Achilles tendon rupture reconstructed using hamstring tendon autograft

BackgroundChronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and augmentation methods are challenging when the defect exceeds 5–6 cm, especially if the distal stump is grossly tendinopathic.MethodsWe describe our method of Achilles tendon reconstruction with ipsilateral semitendinosis autograft and interference screw fixation in a patient with chronic rupture, a 9 cm defect and gross distal tendinopathy.ResultsPatient reported outcome measures consistently demonstrated improved health status at 12 months post surgery: MOXFQ-Index 38–25, EQ5D-5L 18–9, EQ VAS 70–90 and VISA-A 1–64. The patient was back to full daily function, could single leg heel raise and was gradually returning to sport. No complications or adverse events were recorded.ConclusionReconstruction of chronic tears of the Achilles tendon with large defects and gross tendinopathy using an ipsilateral semitendinosis autograft and interference screw fixation can achieve satisfactory improvements in patient reported outcomes up to 1 year post-surgery.     

Reliability of Achilles Tendon Resting Angle and Calf Circumference measurement techniques

BackgroundThe resting angle of the ankle joint may be altered following apparently successful management of Achilles tendon rupture. The reliability of the Achilles Tendon Resting Angle and Calf Circumference measurements was determined.MethodsThree test–retest measurements for reliability assessment were performed on 16 healthy subjects: 10 males and 6 females.ResultsThe mean left Achilles Tendon Resting Angle was mean 50.1° (range [26–61]), ICC 0.92 (CI [0.83–0.97]), SEM 2.4°. The mean right Achilles tendon resting angle was mean 49.9° (range [26–60]), ICC 0.91 (CI [0.80–0.96]), SEM 2.6°. The mean left calf circumference was mean 38.5 cm (range [33.3–44.2]), ICC 0.97 (CI [0.94–0.98]), SEM 0.6 cm, and the mean right calf circumference was mean 38.4 cm (range [33.3–43.6]), ICC 0.97 (CI [0.94–0.99]), SEM 0.5 cm.ConclusionsThe Achilles Tendon Resting Angle and Calf Circumference at 15 cm from the antero-medial joint line had excellent test–retest reliability. These are simple, quick and inexpensive measurements, which have the potential to correlate with tendon elongation and functional outcome. The Achilles tendon resting angle may be used as a guide to tendon length during intra-operative repair and rehabilitation     

Outcomes of open “crown” type v. percutaneous Bunnell type repair of acute Achilles tendon ruptures. Randomized control study

BackgroundThe optimal treatment of acute Achilles tendon ruptures (AATR) is still under debate. The purpose of this study was to evaluate outcomes of open repair comparing with percutaneous procedure for AATR.Methods100 patients with AATR were randomized in two groups: open “crown” type (group A) and percutaneous Bunnell type repair (group B). 87 patients were available for the mean follow up of 27 monthsResultsNo statistically significant difference was observed between groups in ATRS score, leg circumference, single heel rise, Achilles resting angle, time back to work and sports and overall patient satisfaction. Percutaneous technique was much faster. Overall 13 complications occurred in both groups (5 and 8 respectively). No deep infection occurred, no revisions were needed.ConclusionsBoth techniques showed to be effective and safe when using absorbable suture material with a high patient satisfaction and a low complication rate, but percutaneous repair was significantly faster.     

Effect of radiofrequency microtenotomy on degeneration of tendons: An experimental study on rabbits

IntroductionRadiofrequency microtenotomy is used to enhance healing by increasing vascularity in the degenerated tendon. In the present study, the effect of radiofrequency microtenotomy (Rf-mt) treatment on tendon degeneration was investigated.Materials and methodsA total of 32 New Zealand rabbits were enrolled in the current study. Experimental degeneration was performed by injecting prostaglandin E1 (PGE1) into the bilateral Achilles tendons of rabbits. After excluding 4 rabbits with an infection on the injection site, 4 other rabbits were sacrificed to define the histopathologic changes in the tendons. The remaining 24 rabbits were divided into 2 groups: the control group and the Rf-mt group. In the control group, the Rf-mt device was only applied to the Achilles tendon without running the device. In the Rf-mt group, the Rf-mt device was applied bilaterally at the fourth energy level for 500 ms to an area within 2 cm proximal to the insertion site at 0.5 cm intervals in order to form a grid. Six rabbits from each group were sacrificed at 6 and 12 weeks. The Achilles tendons were evaluated histopathologically by a modified Movin scale and by immunohistopathologic staining for vascular endothelial growth factor and type 4 collagen.ResultsAfter the PGE1 injection, findings similar to chronic degenerative tendinopathy were observed. The Rf-mt group showed significant improvement in vascularity in the histopathological and immunohistochemical examination (P < 0.05). However, there was no significant difference in healing between the control and Rf-mt groups (P > 0.05).ConclusionsRf-mt treatment increases vascularity in degenerated tendons but does not create difference to facilitate the healing process comparing control group.     

Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review

ObjectiveTo determine the role of imaging in the diagnosis and monitoring of the Achilles tendon rupture (ATR).Study designSystematic review.Data sourcesPubMed and EMBASE in November 2016.Eligibility criteriaClinical studies providing information on the methods and role of imaging in the diagnosis and monitoring of the ATR were included.ResultsFifty-six studies were included, most concerning the use of ultrasound (n = 37) or MRI (n = 18). Seven studies provided data on the diagnostic accuracy of imaging. Most ultrasound studies used a 7.5 MHz probe (19/32 studies) and scanned the patient bilaterally in prone position, with recent studies tending to use higher frequency probes (r = 0.42). Sensitivity [for detecting a rupture] ranged from 79.6 to 100%; the spread in specificity was large but two studies showed perfect (100%) data. Negative and positive likelihood ratios ranged from 0 to 0.23 and 1.0 to 10 respectively.MRI examination was generally performed with 1.5 Tesla (T) MRI (6/12 studies) with a strong trend for higher T strength in more recent studies (r = 0.71). One study reported a sensitivity of 90.9% and one a specificity of 100%.Although imaging can visualize structure and healing, these results were generally not related to the clinical picture. Overall, ultrasound was recommended over MRI for diagnosis and monitoring. Results of other imaging modalities remain inconclusive.ConclusionThe adjunct role of imaging, especially of ultrasound and MRI, in the diagnosis and monitoring of ATRs was established. It is therefore recommended to rely primarily on the clinical examination and evaluation and to use imaging for ruling out other injuries and providing additional clinical information. More high-quality research is warranted into the diagnostic accuracy of imaging as well as less conventional imaging modalities’ diagnostic and monitoring capabilities.     

Combined flexor hallucis longus tendon transfer and gastrocnemius recession for reconstruction of gapped chronic achilles tendon ruptures

ObjectiveThe aim of this study was to assess the functional outcomes after a combined FHL transfer and a gastrocnemius recession for treatment of chronic ruptures of Achilles tendon with a gap and to investigate the patient's satisfaction about the great toe function after transfer.Material and methods19 patients with chronic rupture of the Achilles tendon with a gap were treated with a flexor halluces longus tendon transfer combined with a gastrocnemius recession, Clinical diagnosis depends on the presence of gap in the tendon on examination, inability of tip toe walking on the affected side and positive calf-squeeze test, MRI was used to confirm the clinical diagnosis. American Orthopedic Foot & Ankle Society hind foot score was used for assessment of the results.ResultsThe AOFAS score improved significantly from a mean of 65 preoperatively to 94 at the last follow up (p < 0.001), there was no significant difference in the final outcome between patients with FHL tendon weaved through the stump of the Achilles tendon and those with trans osseous tunnels, the mean AOFAS score at the last follow up was 94.2, 93.8 respectively, no patient complained of big toe dysfunction.ConclusionManagement of chronic rupture of the Achilles tendon with a gap with flexor halluces longus tendon transfer combined with a gastrocnemius recession is a safe and reliable method with a significantly improved functional outcome, muscle advancement through gastrocnemius recession decreases the length of the gap without affecting the muscle function, flexor halluces longus tendon transfer doesn't harm the big toe function.     

Flexor hallucis longus tendon transfer for chronic Achilles tendon rupture. A retrospective study

BackgroundThe transfer of Flexor Hallucis Longus Tendon (FHL) is an established method for the treatment of chronic Achilles tendon ruptures. An extensive examination of power, strength, endurance and complications related to this procedure is presented.Methods21 patients treated with open FHL transfer for chronic Achilles tendon rupture were studied retrospectively. Medical records were reviewed. The patients were examined with a test battery for triceps surae strength, functional tests and PROMs.ResultsThe median maximal concentric strength was equal,1300 vs 1336 W, comparing affected with unaffected side. The endurance tests showed a larger difference, 219 J vs. 2398 J, respectively. The median AOFAS score was 87. 11 of 21 patients sustained one or more complications; the most common were infection, disturbed wound healing, and clawing of small toes.ConclusionsPatients achieve almost normal maximal strength after open FHL transfer, but endurance is notably lower. The complication rate was high.     

The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging

ObjectiveTo evaluate the feasibility of point-of-care ankle ultrasound compared with magnetic resonance imaging (MRI) for diagnosing major ligaments and Achilles tendon injuries in patients with recurrent ankle sprain and chronic instability, and to evaluate inter-observer reliability between an emergency physician and a musculoskeletal radiology fellow.Material and methodsA prospective cross-sectional study was conducted in an emergency department. Patients with recurrent ankle sprain and chronic instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), distal anterior tibiofibular ligament (ATiFL), deltoid ligament, and Achilles tendon using point-of-care ankle ultrasound. Findings were classified normal, partial tear, and complete tear. MRI was used as the reference standard. We calculated diagnostic values for point-of-care ankle ultrasound for both reviewers and compared them using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and between the two reviewers.ResultsEighty-five patients were enrolled. Point-of-care ankle ultrasound showed acceptable sensitivity (96.4–100%), specificity (95.0–100%), and accuracy (96.5–100%); these performance markers did not differ significantly between reviewers. Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC = 0.846–1.000; musculoskeletal radiology fellow, ICC = 0.930–1.000), as was inter-observer agreement (ICC = 0.873–1.000).ConclusionPoint-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. Moreover, it may reduce the interval from emergency department admission to admission for surgical intervention, and may save costs.     

The influence of an orthopaedic walker boot on forefoot force

BackgroundIn the treatment of an Achilles tendon rupture the patients are commonly equipped with an orthopaedic walker boot with wedges. To what extent this influences the tensile force placed on the Achilles tendon is unclear.PurposeTo assess the forefoot force and describe changes in muscle activity of the medial gastrocnemius, soleus and tibialis anterior when using one or three wedges during ambulation in a weightbearing orthopaedic walker boot.MethodsThe force on the forefoot was measured with a force sensor insole and muscle activity of the medial gastrocnemius, soleus and tibialis anterior were measured using surface electromyography in 10 healthy participants. Three different types of ambulation were performed (walking without crutches (unass.), walking with crutches (+crutch) and walking with crutches and verbal instructions to place body weight on heel (heel + crutch) with one and three heel wedges respectively.FindingsThe total peak force displayed an interaction where forefoot force decreased when wearing three wedges only for the +crutch ambulation type (80 N, p = 0.001) although there was a trend to decrease with three wedges also for the heel + crutch ambulation type (48 N, p = 0.05). The relative peak force on the forefoot showed a main effect with a significant decrease when using three wedges compared to one wedge across all three ambulation types (19.1%, p = 0.009).InterpretationThe force on the forefoot and hereby the Achilles tendon significantly decreased when using three wedges compared to one wedge. These findings have important implications for the rehabilitation post Achilles tendon rupture.     

How early must an acute Achilles tendon rupture be repaired?

An acute Achilles tendon rupture is the most common tendon rupture of the lower extremities, yet the optimal timing for an early surgical repair is unclear. To identify the optimal time for an early surgical repair with favorable results, we evaluated the isokinetic muscle strength and clinical outcomes of early surgical repairs of acute Achilles tendon ruptures performed at different time points after injury. Between January 2011 and July 2015, a total of 65 patients underwent an acute Achilles tendon rupture repair within 1 week after injury. To compare the outcomes at different time points post-injury, we divided patients into 3 groups: group 1, surgical treatment at ≤24 h; group 2, surgery at ≥24 h and ≤48 h; and group 3, surgery at ≥48 hours and ≤1 week. The isokinetic muscle strength in both ankles were measured using a Cybex dynamometer, and the Achilles tendon total rupture score, the modified Tegner scoring system, the visual analog scale was used to assess clinical outcomes. Kruskal-Wallis and Fisher’s exact tests were used to compare multiple results in the 3 groups. No significant differences were found among the groups in terms of ankle isokinetic muscle strength or clinical outcome scores (P > 0.05). The complication rate was low in all groups. There were no significant differences in isokinetic muscle strength or clinical outcomes following acute Achilles tendon rupture repairs performed within 1 week after injury.     

Outcome after operative treatment for chronic versus acute Achilles tendon rupture — A comparative analysis

Background

This study compared outcomes after treatment of acute Achilles tendon (AT) rupture via percutaneous suturing, with those after chronic AT rupture treated via open reconstruction.

The effect of foot type on the Achilles tendon moment arm and biomechanics

BackgroundThe aim was to calculate the Achilles tendon moment arm in different degrees of plantarflexion for pes planus, pes cavus and normal arched feet.Methods99 patients (99 radiographs; 40 males, 59 females; mean age 49 years, SD 15) with a healthy ankle joint and a preoperative weightbearing lateral radiograph of the foot were included. Three groups (pes planus, pes cavus and normal-arched feet) with equal sample sizes (n = 33) were formed. On radiographs, the angle formed between a horizontal line and the line connecting the insertion of the Achilles tendon with the center of rotation of the ankle, was measured. The interrater reliabilities (ICC) of the angle alpha were compared on radiographs and on MRIs. Using the angle alpha, the Achilles tendon moment arm was calculated in different plantarflexion positions.ResultsThe ICC of alpha was higher on radiographs (0.84, [0.73–0.91]) than on MRIs (0.61, [0.27–0.81]). The average alpha was statistically significantly different (normal arched foot 31 degrees (°), pes planus 24°, pes cavus 36°, p = 0.021), resulting in a significant shorter Achilles tendon moment arm for pes cavus than for pes planus (p < 0.0001) and normal arched feet (p = 0.006) in neutral position.ConclusionThe data suggests that it is feasible to use radiographs to measure the Achilles tendon moment arm. The maximum Achilles tendon moment arm is reached at different angles of ankle flexion for pes cavus, pes planus and normal-arched feet. This has to be taken into consideration when planning surgeries.     

5-year results of the 1.5 cm incision Achilles tendon repair

BackgroundTo study a hypothesis that the cost-effective 1.5 cm medial incision Achilles tendon repair technique will provide good functional outcomes which are maintained for over 5 years.MethodProspective study of 12 consecutive cases with a minimal 5-year follow-up were recruited from April 2008 to November 2010. Cases whom were mentally incompetent or those which required concomitant procedures were excluded. Outcomes measures included the numeric pain rating scale, motor power strength, range of motion, functional scoring using the AOFAS hindfoot score and patient’s self-assessment using the Foot and Ankle Outcome Score (FAOS).ResultNo re-ruptures or sural nerve injured were identified after a minimal 5-year follow-up. Pain was minimal at 0.5/10, calf power was 5/5 and ankle range was good (plantarflexion: 38°/dorsiflexion: 21°). The AOFAS hindfoot score was 97.4 and all 5 sub-categories of the Foot and Ankle Outcome Score (FAOS) were good.ConclusionThe 1.5 cm medial incision repair of the Achilles tendon is an economically sound surgical technique, with minimal complications, which gives good medium length functional outcomes.Level of evidenceIV.     

Long-term follow-up after acute achilles tendon rupture — Does treatment strategy influence functional outcomes?

BackgroundPatients struggle to fully recover after an Achilles tendon rupture. Although several studies has investigated surgical and non-surgical treatment, the best treatment is still uncertain. The aim of this study was to investigate long-term patient-reported outcomes and objective measures 4 years after acute Achilles tendon rupture and compare whether outcomes differed between patients treated on basis of the previous regimen preferring surgical treatment and the new regimen preferring functional rehabilitation.MethodsAchilles tendon Total Rupture Score (ATRS), number of re-ruptures and the objective measures; Achilles tendon resting angle, calf circumference, heel-rise height, and muscle endurance were measured at a 4-year follow-up. Patients were recruited from Aalborg University Hospital.ResultsSeventy-six patients were included (29% female). The mean ATRS was 71.4 (95% CI: 65.8 to 77.1) at 4 years follow-up. No difference in ATRS was observed between Previous regimen and New regimen at any timepoint (time x group interaction, (p = 0.851). The injured side was still significantly impaired compared with the non-injured side in terms of all objective measures. Impairments in objective measures were not dependent on the preferred treatment strategy.ConclusionsPatient reported impairments and objective functional deficits persist 4 years after an acute Achilles tendon rupture. No differences in patient reported outcome or objective measures at the 4 years follow-up was observed between the old treatment regimen preferring surgery compared with the new treatment regimen preferring functional rehabilitation.