Is Achillon repair safe and reliable in delayed presentation Achilles tendon rupture? A five-year follow-up

Background

To assess the outcome of delayed repair of ruptured Achilles tendon using the Achillon mini-open technique.

Surgical versus non-surgical treatment for acute Achilles’ tendon rupture. A systematic review of literature and meta-analysis

BackgroundAchilles’ tendon injury affect 31.17 per 100,000 yearly, it has a major impact on quality of life of affected patients, mostly active young individuals. Different management options exist ranging from conservative treatment, to operative repair either open or percutaneous repair. No consensus has been reached on which treatment modality is preferred for each patient. In this study we systematically reviewed the literature for available evidence regarding management of acute Achilles’ tendon rupture.MethodsThis systematic review consisted of 9 studies, including a systematic search of literature (PubMed, SCOPUS, and The Cochrane Library), selection of studies, extraction of study characteristics, assessment of methodological quality and bias and extraction of data on clinical outcomes and their comparisons between different surgical groups.ResultsA total of 9 studies were included, 822 patients were extracted from the included studies. Of the 822 patients, 415 (50.4%) had undergone surgical intervention and 407 (49.6%) had received non-surgical treatment. The minimum follow-up duration was 12 months. The left Achilles' tendon was relatively more prone to rupture. The interval from injury to treatment was within 2 to 14 days. Five 5 different surgical techniques were used; end to end, modified Kessler, augmented repair, Krackow type and interrupted circumferential stitch. Operative repair was found to significantly decrease rupture rate (Risk Ratio of 0.36, 95% CI 0.21–0.64; P = 0.0005) with higher risk of wound complications. No statistically significant difference between the two groups in functional outcome scores and range of motion.ConclusionWe concluded that surgical technique lowers the risk of rerupture rate but associated with higher complication rate which can be reduced by using the minimally invasive techniques. Multicenter randomized clinical trials are needed to obtain a high-quality level of evidence for the comparison between the different modified surgical techniques and the gap effect on making different decision of managements.     

Is percutaneous repair of the Achilles tendon a safe technique? A study of 124 cases

Ma and Griffith first described in 1977 a percutaneous technique for the repair of acute Achilles tendon rupture. In 1992, Delponte popularised a new percutaneous technique with Tenolig. The authors report a series of 124 cases of Achilles tendon rupture treated with Tenolig in their institution from 1993 to 1998. There were 79 men and 45 women. The mean age was 41.5 years, with a peak from 30 to 39 years. The rupture occurred during sports activities in 69 cases. The mean duration of follow-up was 1.9 years. Surgical complications noted were: unbending of one of the harpoon wires in 5 cases, rupture of the harpoon wire in one case and tendon re-rupture in 12 cases. The rate of re-rupture was similar to the rate noted with conservative treatment (10%). Skin necrosis at the entrance wound was noted in 10 cases, and injury of the sural nerve in 8 cases. Full weight-bearing without crutches was regained for 95% of patients within 3 months. In conclusion, this report shows a high rate of re-rupture and sural nerve entrapment with percutaneous surgery (Tenolig). The high rate of re-rupture can be due to the progressive but immediate weight-bearing allowed without an orthosis, or to inadequate apposition of the tendon ends, or to delay before repair. The high rate of sural nerve entrapment is due to its proximity to the Achilles tendon. We believe that a limited open technique is more reliable and has the advantage of allowing direct visualisation of the repair site and controlling adequate apposition of the tendon ends.     

Primary testicular lymphoma—A single center experience and review of literature

ObjectiveThe purpose of this study is to evaluate the clinical characteristics, pathology, treatment outcomes, and survival of primary testicular lymphoma (PTL) patients treated at our hospital after 1990. Related literature was reviewed.Materials and methodsWe retrospectively enrolled patients diagnosed with PTL between January 1990 and September 2013 in our institute. Clinical features, pathology, and overall survival were analyzed.Results24 patients were enrolled. They had a mean age at diagnosis of 65.0 years (range 10–84 y), mean follow-up duration 57.0 months (range 3–182 mo), and median overall survival of 38 months (range 4.0–184.7 mo). The most common pathology subtype was diffuse large B-cell lymphoma (n = 21, 87.5%). Fourteen patients (58.3%) achieved complete remission of disease and five patients (20.8%) achieved partial remission after treatment. Three patients had a relapse of disease after complete remission: one in the brain parenchyma, one in the pelvis soft tissue and omentum, and one in the left pyriform muscle. Three patients had metastasis after partial remission of disease: two in the brain parenchyma and one in the cauda equina. By univariate analysis, the factors significantly associated with superior overall survival were primary tumor diameter < 7.5 cm, serum lactate dehydrogenase ≤ 250 U/L, Ann-Arbor Stage IE/II, and International Prognostic Index (IPI) ≤ 1 (p < 0.05). Rituximab-containing treatment did not show overall survival benefits in our series. By multivariate analysis, IPI ≤ 1 showed statistical significance (p = 0.019), suggesting a potential prognostic value of IPI in evaluating PTL patients.ConclusionsThe overall survival of PTL patients is poor, especially those with extensive disease (Stage III/IV). The IPI have a prognostic role in PTL. The use of rituximab in the treatment regimen of PTL does not seem to improve survival in our series.     

Accelerated rehabilitation following Achilles tendon repair after acute rupture – Development of an evidence-based treatment protocol

The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period. Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently, the aim of our study was to systematically search the evidence available and define a precise rehabilitation programme after operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence.We performed a systematic literature search in Medline, Embase and Cochrane library. We identified twelve randomized controlled trials comparing different treatment regimes after operative repair of the Achilles tendon.Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity. Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens time to return to work and sports significantly. Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation. No study found an increased rerupture rate for the more progressive treatment.In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied.     

Chronic rupture of Achilles tendon: is the percutaneous suture technique effective?

Background We report the long-term results of the surgical treatment of chronic rupture of the Achilles tendon using percutaneous suturing under local anesthesia. Patients and methods We operated on 22 patients with median age of 50 years (29–72) with chronic rupture of Achilles tendon between 1991 and 2005. The median time from injury to surgery was 7.1 weeks (4–40). We used percutaneous surgical technique similar to a technique described by Ma and Griffith (1977, Clin Orthop Relat Res 128:247–255) and Kosanović (1994, Arch Orthop Trauma Surgery 113:177–179). Eighteen (82%) patients attended the clinical review at a mean of 67 months (14–176). During follow up, patients were asked about pain, stiffness, weakness of the calf, footwear restrictions, occupation and level of activity before and after injury (Tegner score), influence of injury on ADL activities and satisfaction with treatment. The passive and active range of movement of the ankle and the power of isometric plantar flexion were measured, and the endurance test was performed. Functional assessment was performed using a Leppilahti clinical scoring scale and a modified Merkel score Results Complete healing of the tendon was achieved in 21 patients (95%). In 17 patients (77%) the postoperative course was complications free. There were no reruptures during the observation period. All were able to stand on the tiptoe of the injured leg. The operated leg had a mean of 87.5% of the isometric power compared with the uninjured leg (p = NS). On an average they could stand on toes and raise the heel 13 times on side with the ruptured tendon. The Leppilahti scoring scale revealed a result that was excellent for 11 patients (62%), good for 2 (11%), fair for 5 (28%) and no one had poor result. The average score was 83.3 (60–100). Eighty-three percent of patients stated that the result of surgery was very good and 11% rated it as good. Fourteen patients (78%) returned to same level of activity at median 7 months after surgery. Conclusions Our series is one of the largest to be reported for the treatment of chronic rupture. Our technique offers a considerable advantage; it is minimal invasive, easy to perform with no associated harvesting morbidity and increased patient acceptance. We recommend this technique for the treatment of chronic rupture of Achilles tendon.     

Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study—preliminary report

Purpose

Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results.

Method

We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon® device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months.

Results

No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports.

Conclusion

After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.     

Is the use of specific scoring system still justified in early evaluation of acute pancreatitis?

STUDY AIM: Acute pancreatitis (AP) is a potentially life-threatening disease in which specific severity scoring system has been developed. The aim of this prospective study was to compare efficiency of the general severity of illness scoring system and the most widely used specific scoring system of AP in order to simplify the initial monitoring of AP at the time of admission. PATIENTS AND METHODS: Eighty-seven patients with AP were hospitalized in the same center. There were 47 men and 40 women (mean age: 57 +/- 16 years). Specific scores (Ranson, Imrie, Blarney) and general severity of illness scores (SAPSI, SAPS II, Apache II) were calculated for each patient. Radiological scores (Hill, Balthazar) were also calculated when TDM was early performed (80%). Each scoring system was correlated with severity, morbidity and mortality of AP and its predictive value evaluated by the area under the ROC curve. RESULTS: Aetiology of AP was predominantly biliary (20%) and alcoholic (70%). Eight per cent of the patients died and 29% of AP were classified as severe according to the Atlanta Congress Score. Morbidity rate was 40%. All the scoring systems were significantly correlated with mortality and exhibit ROC curve area between 0.77 and 0.84, resulting in a similar prediction of death. CONCLUSION: Specific scoring system and general severity of illness scoring system have the same predictive efficiency in acute pancreatitis. The use of the specificity scoring system seems to be no more justified in acute pancreatitis.     

Treatment of distal biceps tendon rupture: why,when, how? Analysis of literature and our experience

Introduction

The rupture of the distal biceps tendon is a relatively uncommon lesion. Even if conservative treatment may be an option in low demanding patients, young and active subjects may benefit from an early surgical reinsertion. Many techniques and fixation devices have been described, but in the literature, there are no clinical evidences that show the superiority of any of these. In this article, we report an analysis of the “state of the art” and our case series of surgical reinsertion with the double approach transosseous technique.

Materials and methods

Between 2003 and 2013, 26 patients underwent surgical reinsertion, either for acute or for chronic lesions of distal biceps tendon. We evaluated 21 acute cases treated with double approach using DASH and SECEC Elbow Scores. The mean follow-up was 22 months. Range of motion, supination and flexion strength were also recorded.

Results

Mean final ROM was 6–132° in F/E and 89–0–87° in P/S; flexion and supination strength were 96 and 88 % compared to the opposite side. The main complications were two cases of heterotopic ossifications: one asymptomatic fracture of the proximal radius and one temporary neurapraxia of the radial nerve.

Conclusions

Analysing the literature and our outcomes, we underline the importance of timing for surgery, in young and compliant patients, with a valid rehabilitation protocol for excellent results. The choice of surgical technique remains controversial, and we believe that the double approach transosseous reinsertion is a safe, costless and relatively non-invasive technique, offering satisfactory results when performed early.

     

Subcutaneous Achilles tendon rupture: A comparison between open technique and mini-invasive tenorrhaphy with Achillon® suture system

BackgroundSurgical management of Achilles tendon rupture is still controversial: open techniques have a higher rate of soft tissue complications but a lower incidence of re-rupture than percutaneous tenorrhaphies. The aim of our retrospective study was to analyze and compare clinical and functional results in patients treated with either the conventional open or minimally invasive suture treatment with the Achillon^® system.MethodsA retrospective review of 140 patients was performed; 72 were treated with open tenorrhaphy, 68 with the minimally invasive Achillon^® suture system.ResultsWith a comparable re-rupture rate, there was a statistically significant reduction in surgical time, incidence of minor complications, time required to return to sport activities and return to work in the minimally invasive group.ConclusionsAchillon^® mini-invasive suture system is a reliable tool for the Achilles tendon ruptures, able to reduce the incidence of soft tissues complications if compared to the classic open tenorrhaphy, while maintaining strength of the suture and leading to superimposed functional outcomes.     

Mini-invasive surgical repair of the Achilles tendon—does it reduce post-operative morbidity?

The surgical benefit of minimally invasive tendo Achilles repair (n = 25) with early weight-bearing mobilisation after rupture of the tendo Achilles was compared with operative treatment using an open technique (n = 34) with full weight-bearing after 8 weeks of surgical repair. The minimally invasive technique provided no evidence of wound problems and a functional benefit from early weight-bearing mobilisation. However, we noted that increased post-operative morbidity in terms of wound infection (n = 7) leading to delayed wound healing and wound pain requiring opiate-based analgesia post-operatively in the open repair group may have an additional impact on the patients and health care providers. This study showed that the mini-invasive open surgical repair of the Achilles tendon with the Achillon instrument and early weight-bearing mobilisation in an orthosis for the accelerated rehabilitation may offer cost-effectiveness and less financial burden on the health care provider in terms of associated nursing and physiotherapy costs.     

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.     

Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle?

Purpose

The purpose of the study is to explain the cause–effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis.

Methods

Three cryopreserved cadavers (three men, three left legs) were examined to assess the anatomic connection between the retrocalcaneal bursa and the Achilles tendon (distal and anterior fibers). Blue triptan medium contrast was injected.

Results

An unexpected connection between the retrocalcaneal bursa and the anterior fibers of the Achilles tendon was found in all instances.

Conclusions

Local corticosteroid injection of the retrocalcaneal bursa may help the symptoms of retrocalcanear bursitis, but pose a risk of Achilles tendon rupture. This risk–benefit has to be taken into account when corticosteroid injections are prescribed to professional and high-level athletes.     

Classification of Achilles tendon shortening induced by scar contracture and corresponding treatment strategies for pediatric patients — A single unit experience

BackgroundAchilles tendon shortening of pediatric patients caused by scar contracture poses a challenge for us. It always impairs walking function. In this article, we attempted to introduce a new classification of Achilles tendon shortening of pediatric patients and corresponding treatment strategies in our single center.MethodsFrom 2001 to 2018, 65 patients (aging from 13 to 17-years-old, 34 females and 31 males, 21 cases with unilateral Achilles tendon shortening and 44 cases with bilateral Achilles tendon shortening) were recruited. The causes included trauma (n = 13), scald (n = 20) and burn (n = 32). The distance between the heel and the ground was from 3 to 18 cm. They were classified into three types: ≤5 cm, mild, n = 9; 5–10 cm, moderate, n = 30; ≥10 cm, serious, n = 26. They had a history from 7 months to 4 years (28 cases with less than 1.5 years and 37 cases with more than 1.5 years). Treatment methods: Scar-Achilles-Tendon (SAT) flaps and skin graft were used for moderate cases before special external fixation shoes were used for fixation for at least 6 months. External special shoes fixation was used for mild cases except 5cases still received SAT flap and skin graft. In serious cases, bone extraction was used for at least 6 months before receiving SAT flap and skin graft.ResultsThe distance between the heel and the ground was 0 cm after treatment in 54 cases (mild, n = 9; moderate, n = 28; serious, n = 18). Recurrence was found in 11 cases (mild, n = 0; moderate, n = 5; serious, n = 6) after six months follow-up. There were 13 cases of tangential excision of eschar and 8 cases of escharectomy (P < 0.05) with flap necrosis affection. Among them, 9 cases with a medical history of less than 1.5 years had partial necrosis, 6 cases with a medical history of more than 1.5 years had partial flap necrosis(P < 0.05). Local necrosis was covered by skin graft again. Bone exposure was found in 5 serious cases. It was repaired by negative pressure therapy first and then skin graft was used. The walking ability (P < 0.05) and function (P < 0.05) of lower limbs were statistically improved after treatment.ConclusionsDifferent methods can be used according to the shortening degree of Achilles tendon of pediatric patients based on the new classification, which may be useful for future clinical work.