Surgical Correction of Haglund's Triad Using a Central Tendon-Splitting Approach: A Retrospective Outcomes Study

We evaluated the surgical outcomes of Haglund's triad using a central tendon-splitting approach, with Achilles tendon partial detachment and debridement, excision of the retrocalcaneal bursa, resection of Haglund's prominence, and reattachment of the Achilles tendon. The medical records of 22 patients (22 heels) who had undergone surgical correction of Haglund's triad from January 2010 to December 2015 were reviewed retrospectively. The visual analog scale pain score, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical and mental component scores were prospectively collected preoperatively, 6 months postoperatively, and at the last visit. The scores of a subjective question involving satisfaction were prospectively collected at the last visit. Possible risk factors were also evaluated. We reviewed the data from 12 females and 10 males, with the mean age of 59.2 ± 7.3 years and a mean follow-up duration of 15.1 ± 4.6 months. Significant improvement was found in the mean visual analog scale pain score, average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical component scale score. The overall satisfaction rate was 77.3% (17 of 22). Postoperative complications included 2 cases of delayed wound healing and 1 case of sensation loss over the heel wound. No Achilles tendon rupture or wound infection developed. Gender and body mass index did not affect the surgical outcomes. The surgical technique we used for Haglund's triad provided effective pain relief, function improvement, and overall enhancement of patients' health condition. More research is required to further evaluate the outcomes of our surgical approach to treat Haglund's triad and the possible risk factors.     

Haglund's Deformity as a Cause of Acute Achilles Tendon Rupture: A Case Report

Achilles tendon rupture is a common problem affecting both high level and casual athletes. Haglund´s deformity is an abnormality of the postero-superior part of the calcaneus, which often leads to retro-calcaneal bursitis as well as thickening and inflammation of the calcaneal tendon, a combination of pathologies known as Haglund's syndrome. We report a rare case of a relapse Achilles tendon rupture in a 39-year-old professional handball player with a pronounced painful Haglund´s deformity treated with tendon debridement and reattachment using the Arthrex Speedbridge® system. This case report illustrates a rarely described operative and post-operative management of this unusual combination of Achilles tendon rupture and Haglund´s deformity.     

Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis

Objective

In Achilles tendon injuries, it is suggested that a pathological continuum might be evident from the healthy Achilles tendon to Achilles tendinopathy to Achilles tendon rupture. As such, risk factors for both tendinopathy and rupture should be the same.

Hypothesis

Hereditary and medical risk factors for Achilles tendinopathy and Achilles tendon rupture are the same to a similar extent in a matched pair analysis.

Design

Matched pair study; level of evidence: 3.

Setting

Recreational sportsmen as well as athletes on national level.

Patients

566 questionnaires were analysed. 310 subjects were allocated to 3 groups (A, B, C) after matching the pairs for age, weight, height and gender: (A) healthy Achilles tendons (n?=?89, age 39?±?11?years, BMI 25.1?±?3.9, females 36%), (B) chronic Achilles tendinopathy (n?=?161, age 41?±?11?years, BMI 24.4?±?3.7, females 34%), (C) acute Achilles tendon rupture (n?=?60, age 40?±?9?years, BMI 25.2?±?3.2, females 27%).

Results

We found a positive family history of Achilles tendinopathy as a risk factor for Achilles tendinopathy (OR: 4.8, 95% CI: 1.1–21.4; p?=?0.023), but not for Achilles tendon rupture (OR: 4.0, 95% CI 0.7–21.1, p?=?0.118). Smoking and cardiac diseases had a lower incidence in Achilles tendinopathy than in healthy subjects (both p?=?0.001), while cardiovascular medication did not change the risk profile.

Conclusion

Identifying risk factors associated with Achilles tendon disorders has a high clinical relevance regarding the development and implementation of prevention strategies and programs. This cross-sectional study identified a positive family history as a significant solitary risk factor for Achilles tendinopathy, increasing the risk fivefold. However, in this matched pair analysis excluding age, weight, height and gender as risk factors no further factor necessarily increases the risk for either Achilles tendinopathy or Achilles tendon rupture.     

The Achilles Tendon Insertion is Crescent-shaped: An In Vitro Anatomic Investigation

Anatomic and operative textbooks and current literature do not clearly describe the Achilles tendon interface to the calcaneal tuberosity. We dissected 51 specimens to identify the detailed anatomy of the Achilles tendon insertion. Achilles tendon fascicles expanded from the anterior aspect of the distal Achilles tendon over the retrocalcaneal bursa to the anterior part of the Haglund’s tuberosity in nearly half of the specimens. The insertion of the transverse section of the Achilles tendon regularly had a crescent-shape corresponding to the posterior calcaneal prominence. In transverse sections, all specimens had a curved appearance with a radius of curvature ranging from 13.8 mm to 43.6 mm (mean, 20.4 mm) and Achilles tendon extensions to the lateral and medial calcaneal surfaces reached 1.0 mm (mean) and 3.5 mm (mean) anterior in relation to the most posterior point of the calcaneal tuberosity. Knowledge of the arcuate configuration and of the medial and lateral extensions of the plantaris and the Achilles tendon insertion with respect to the transverse plane is important to avoid iatrogenic complications during resection of Haglund’s tuberosity. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research.     

Single-row Versus Double-row Repair of the Distal Achilles Tendon: A Biomechanical Comparison

Surgery for recalcitrant insertional Achilles tendinopathy often consists of partial or total release of the insertion site, debridement of the diseased portion of the tendon, calcaneal ostectomy, and reattachment of the Achilles to the calcaneus. Although single-row and double-row techniques exist for repair of the detached Achilles tendon, biomechanical data are lacking to support one technique over the other. Based on data extrapolated from the study of rotator cuff repairs, we hypothesized that a double-row construct would provide superior fixation strength over a single-row repair. Eighteen human cadaveric Achilles tendons (9 matched pairs) with attached calcanei were repaired with single-row or double-row techniques. Specimens were mounted in a servohydraulic materials testing machine, subjected to a preconditioning cycle, and loaded to failure. Failure was defined as suture breakage or pullout, midsubstance tendon rupture, or anchor pullout. Among the failures were 12 suture failures, 5 proximal-row anchor failures, and 1 distal-row anchor failure. No midsubstance tendon ruptures or testing apparatus failures were observed. There were no statistically significant differences in the peak load to failure between the single-row and double-row repairs (p = .46). Similarly, no significant differences were observed with regards to mean energy expenditure to failure (p = .069). The present study demonstrated no biomechanical advantages of the double-row repair over a single-row repair. Despite the lack of a clear biomechanical advantage, there may exist clinical advantages of a double-row repair, such as reduction in knot prominence and restoration of the Achilles footprint.     

Severe Functional Debilitations After Complications Associated With Acute Achilles Tendon Rupture With 9 Years of Follow-Up

The purpose of the present study was to investigate the long-term effect of deep infection, sural nerve injury, and repeat rupture in the treatment of acute Achilles tendon rupture. A total of 324 patients had made a claim to the Danish Patient Insurance Association from 1992 to 2010 for a complication after acute Achilles tendon rupture. Of the 324 patients, 119 (36.7%) (77 [64.7%] males and 42 [35.3%] females) returned the Achilles tendon total rupture score and the 36-item short-form survey questionnaires. Patients with deep infection (n = 10), sural nerve injury (n = 10), and repeat rupture (n = 16) participated in a follow-up investigation. The mean follow-up period was 8.9 (range 3 to 21) years. The mean Achilles tendon total rupture score was 49 ± 27. The summary scores of the physical component and mental components scales of the 36-item Short Form Survey were 43 ± 11 and 52 ± 11, respectively. No significant differences were found among the subpopulations with deep infection, injury to the sural nerve, or repeat rupture. The physical evaluation investigating tendon length and heel rise work revealed a statistically significant difference between the affected and unaffected limb after repeat rupture (p < .01) but not after injury to the sural nerve (p > .05) or deep infection (p > .05). In conclusion, patients with from a complication after acute Achilles tendon rupture had a remarkable reduction of the Achilles tendon total rupture score and physical component scale score at mean follow-up point of 9 years. Patients with repeat rupture had a significant elongation of the tendon and reduction of strength in the affected limb.     

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.     

Overload and neovascularization of Achilles tendons in young artistic and rhythmic gymnasts compared with controls: an observational study

The incidence of Achilles tendinopathy is very high in young female gymnasts (17.5 %). According to literature, ecography screenings show the tendons thickening, but at the same time it does not reveal a direct link to the clinical picture. The neovessels are involved in the pathophysiological process of Achilles tendinopathy. For this reason, we wanted to verify there between perfusion tendon values and the type of sport activity. We performed a clinical observational study monitoring the oximetry of the Achilles tendon and the epidemiological data of 52 elite female (artistic and rhythmic) gymnasts versus 21 age-matched controls. Analyzing the main limb, we revealed statistically higher oximetry values in the artistic gymnasts group (69.5 %) compared to the rhythmic gymnasts group (67.1 %) (t = 2.13; p = 0.01) and the sedentary group (66.2 %) (t = 2.70; p = 0.004), but we did not find any differences between rhythmic gymnasts group and the sedentary group (t = 0.68; p = 0.24). The multiple logistic regression model highlighted that the oximetry value of the main limb is not influenced by age, knowledge of the main limb, years of general and gymnastic sports activity (p > 0.05). We discovered an increase of Achilles tendon perfusion in the main limb in the artistic gymnast group. We hypothesize that specific figures of artistic sports activity are responsible for muscle overload and gastrocnemius-soleus group and, at the same time, these figures cause hyperperfusion of the tendon. Prospective longitudinal studies could explain if this could become a predictive sign of the next Achilles tendinopathy onset.     

Arthroscopy and Endoscopy of the Foot and Ankle: Indications for New Techniques

The scope of arthroscopy and endoscopy of the foot and ankle is expanding. New techniques are emerging to deal with diverse ankle pathology. Some of the conditions that can be dealt with arthroscopically are as follows: hallux valgus deformity, lesser toe deformity, first metatarsophalangeal instability, cock-up deformity of the big toe, peroneal tendon instability, lateral ankle and subtalar instability, hindfoot deformity or arthrosis, first metatarsocuneiform hypermobility, Lisfranc joint arthrosis, various stages of posterior tibial tendon insufficiency, foot and ankle arthrofibrosis, late complications after calcaneal fracture, acute and chronic Achilles tendon rupture, insertional Achilles tendinopathy, entrapment of the first branch of the lateral plantar nerve, Freiberg’s infarction, flexor digitorum longus tenosynovitis, flexor hallucis longus pathology, calcaneonavicular coalition or “too-long” anterior process of the calcaneus, and ganglions. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery.     

Results of operative treatment for recalcitrant retrocalcaneal bursitis and midportion Achilles tendinopathy in athletes

Background

The results of operative treatment for recalcitrant midportion Achilles tendinopathy and recalcitrant retrocalcaneal bursitis were evaluated using the patient administered, disease specific, and validated VISA-A-G questionnaire.

Methods

A cohort of 89 patients was prospectively followed. These patients underwent operations for sport induced midportion Achilles tendinopathy (39 procedures) or retrocalcaneal bursitis (55 procedures). Depending on the individual intraoperative findings the patients of either disease were treated with two respective operative modifications (tendon repair or no tendon repair). Preoperative and follow-up status (3, 6, and 12 months) were investigated using the VISA-A-G questionnaire.

Results

Preoperatively, the four groups scored from 37.0 ± 17.6 to 45.9 ± 15.2 (p = 0.376–0.993) on the VISA-A-G questionnaire. Six and 12 months postoperatively, the VISA-A-G scores improved significantly (p < 0.001). Twelve months postoperatively, the groups’ scores were not different (p = 0.100–0.952) and ranged from 80.8 ± 17.9 to 90.3 ± 10.6.

Conclusion

Retrocalcaneal bursitis and midportion Achilles tendinopathy responded equally well to operative treatment. When repaired, additional tendon lesions did not influence this result. We demand to differentiate not only between midportion Achilles tendinopathy and retrocalcaneal bursitis but also to identify additional Achilles tendon lesions to specifically address these lesions during operative procedures.

Level of evidence

Prospective mixed cohort study.     

Minimally Invasive Achilles Tendon Stripping for the Management of Tendinopathy of the Main Body of the Achilles Tendon

Achilles tendinopathy is a common cause of disability. New nerves fibers grow from the paratenon into the Achilles tendon, and they could play a central role in the development of pain. We report the results of minimally invasive Achilles tendon stripping for Achilles tendinopathy in 47 active patients. The Victorian Institute of Sports Assessment-Achilles questionnaire score improved from 53.8 preoperatively to 85.3 postoperatively (p < .001). After a mean follow-up period of 40.5 months, 41 patients had resumed sporting activities at an average of 3.5 months postoperatively. A sural nerve injury was recorded in 5 patients (10.6%), and all 5 complications occurred during the first 12 cases. As a result, the technique was slightly modified, and no sural nerve neuropathy was observed subsequently. One superficial infection (2.1%) was recorded. Minimally invasive Achilles tendon stripping seems to be an effective, technically simple, and inexpensive treatment of Achilles tendinopathy. Further randomized controlled trials involving more patients are needed to confirm these outcomes.     

Comparison of Four Methods for Percutaneous Achilles Tendon Lengthening: A Cadaveric Study

Percutaneous Achilles tendon lengthening can result in Achilles tendon rupture. This complication has been controversially linked to torsion effects in the Achilles tendon. Routine percutaneous triple-hemisection techniques (group A), rotary triple-hemisection (group B), distal double-hemisection (group C), and proximal double-hemisection (group D) were compared in cadaveric specimens to provide insights into the mechanism of uneven incision lengthening and inadvertent Achilles tendon rupture. The degree of Achilles tendon torsion on various planes was measured in 20 lower limb pairs from fresh cadavers. The increase in postoperative maximum ankle joint dorsiflexion degree and the length of the lengthened Achilles tendon were greater in group B (p < .05) and group C (p < .05) compared with the routine percutaneous triple-hemisection technique (group A). The width of the tensile gap of the distal incision was significantly greater in group B (p < .05) and group C (p < .05) compared with that in group A. Rotary triple-hemisection was shown to eliminate the effect of Achilles tendon torsion on percutaneous Achilles tendon lengthening. Because proximal double-hemisection is performed away from the distal Achilles tendon where the fibers rotate sharply, the technique results in more even extension of the incisions and achieves a greater increase in the maximum degree of ankle joint dorsiflexion. Uneven incision lengthening was observed with the routine percutaneous triple-hemisection and distal double-hemisection techniques. Achilles tendon torsion affected the surgical outcomes. Rotary triple-hemisection and proximal double-hemisection techniques resulted in more even extension of the incisions and achieved a greater increase in the degree of maximum ankle joint dorsiflexion.     

Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis

BACKGROUND: The traditional operative management of Haglund deformity and retrocalcaneal bursitis consists of an open excision of the inflamed bursa, resection of the posterosuperior calcaneal tuberosity, and debridement of the Achilles tendinopathy. In an effort to reduce morbidity and recovery time, an endoscopic technique was used for the management of this condition. METHODS: Thirty consecutive patients (32 heels) who had retrocalcaneal bursitis unrelieved by nonoperative measures were treated with the endoscopic technique. Two portals were created, one laterally and one medially, over the posterosuperior portion of the calcaneus to gain access to the retrocalcaneal space. The inflamed bursal tissue was removed, and the prominent bone was resected. Patients were evaluated preoperatively and postoperatively with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. RESULTS: The mean followup was 35 months. Twenty-eight patients (30 heels) were available for followup. The AOFAS scores averaged 62 preoperatively and 97 postoperatively. There were 26 excellent results, three good results and one poor result. One major and one minor complication occurred: an Achilles tendon rupture three weeks after surgery and residual pain and swelling that required reoperation through an open procedure. There were no wound complications or postoperative infections. CONCLUSIONS: The endoscopic technique can be done outpatient and has a low morbidity and high patient satisfaction. The time to return to normal activity level is short. Sufficient exposure of the Achilles tendon and removal of the calcaneal prominence and retrocalcaneal bursa can be done effectively using an endoscopic technique.     

Clinical presentation and surgical management of chronic Achilles tendon disorders — A retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon

Background

Non-invasive treatment is not always successful in patients with Achilles tendon disorders, and surgical treatment is instituted as the next step. There is sparse knowledge about the diagnoses, pain levels before surgery, surgically confirmed pathologies and postoperative complications in large patient groups.

Short-Term Outcomes of Open Reduction and Internal Fixation for Sanders Type III Calcaneal Fractures With and Without Bone Grafts

Calcaneal fractures, often caused by a fall from a height, are the most common injuries encountered by orthopedic surgeons. Currently, open anatomic reduction and internal fixation (ORIF) is considered a valuable treatment of displaced intraarticular fractures of the calcaneus; however, the need for bone grafting in the treatment is still controversial. Therefore, in the present study, we investigated the outcomes of 2 methods (with and without bone grafting) used for the surgical treatment of Sanders type III calcaneal fractures. From January 2013 to September 2015, 57 cases (55 patients) with displaced Sanders type III calcaneal fractures (53 unilateral and 2 bilateral) were enrolled. The patients were divided into 2 groups: group I was treated by ORIF with bone grafting (n = 28) and group II was treated by ORIF without bone grafting (n = 29). The radiologic evaluation included Böhler's angle, Gissane's angle, and the height and width of the calcaneum. In addition, the American Orthopaedic Foot and Ankle Society questionnaires and visual analog scale were completed by the patients. During the follow-up period, no differences were found in the outcome measures (Böhler's angle, p = .447; Gissane's angle, p = .599; calcaneal height, p = .065; calcaneal width p = .077; and American Orthopaedic Foot and Ankle Society questionnaires, p = .282) with or without bone grafting. The only difference between the 2 groups was the occurrence of postoperative pain (p = .024 and p = ≤ .05), which was greater in the patients who had undergone bone grafting. We have provided evidence that bone grafting with internal fixation in the treatment of intraarticular calcaneal fractures failed to improve the restoration of Böhler's angle or Gissane's angle. No statistically significant difference was found in the short-term outcomes between the 2 methods used for the surgical treatment of Sanders type III calcaneal fractures.     

A Biomechanical Analysis of Interference Screw Versus Bone Tunnel Fixation of Flexor Hallucis Longus Tendon Transfers to the Calcaneus

The flexor hallucis longus tendon transfer is commonly used to restore function in chronic Achilles tendon ruptures and chronic Achilles tendinopathy. The tendon is often secured to the calcaneus either through a bone tunnel or by an interference screw. We hypothesized that tenodesis using the bone tunnel method would be mechanically superior to interference screw fixation for flexor hallucis longus transfers. Eight matched pairs of cadaveric specimens were assigned randomly to the bone tunnel or interference screw technique and were loaded to failure. Biomechanical analysis was performed to evaluate the ultimate strength, peak stress, Young's modulus, failure strain, and strain energy. Unpaired comparison, paired comparison, and linear regression analyses were used to determine statistical significance. A slight 22% ± 9% decrease in Young's modulus and a 52% ± 18% increase of strain energy were found in the interference screw group. However, no differences in ultimate strength, peak stress, or failure strain were seen between the 2 groups on paired comparison. Our findings suggest that interference screw fixation provides similar spontaneous biomechanical properties to the use of a bone tunnel for flexor hallucis longus transfer to the calcaneus. The interference screw is a practical option for fixation of the flexor hallucis longus tendon to the calcaneus and can be performed through a single incision approach.     

Is Calcaneal Inclination Higher in Patients with Insertional Achilles Tendinosis? A Case-controlled,Cross-sectional Study

Insertional Achilles tendinosis is a condition where a patient complains of isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. It has been suggested that this condition is associated with cavus foot deformity. However, to our knowledge, there is no study that has confirmed this observation. We carried out a cross-sectional, case-controlled study to explore the association of increased calcaneal inclination—a surgically important characteristic of cavus foot deformity—with insertional Achilles tendinosis. Patients with Achilles tendinosis and matched controls without the pathology were compared. Although a statistically significant difference was detected in calcaneal inclination angle between these 2 groups (p = .038), we felt that the difference was not clinically significant (calcaneal inclination angle = 20.9 vs. 18.9, respectively). Within the limitations of the study, we conclude that there is no clinically significant difference in calcaneal inclination between those with or without insertional Achilles tendinosis.     

Effect of Ankle Motion and Tensile Stress at the Achilles Tendon on the Contact Pressure Between the Achilles Tendon and the Calcaneus

Impingement between the Achilles tendon and the posterosuperior prominence of the calcaneus is considered to be a cause of insertional Achilles tendinopathy. The corresponding treatment intends to reduce tensile stress from calf muscles and avoid hyper-dorsiflexion of the ankle joint for decreasing the contact pressure; however, no study has reported on whether these treatments can decrease impingement. Thus, this study investigated the hypothesis that the tensile stress of the Achilles tendon and ankle motion affect the contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus. Six fresh-frozen cadaveric lower leg specimens were procured. Each specimen was set to a custom foot-loading frame and loaded with a ground reaction force of 40 N and a tensile load of 70 N along the Achilles tendon. The contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus was measured using a miniature pressure sensor under different tensile loadings of the Achilles tendon at the neutral ankle position. Similarly, the contact pressures during the ankle motion from a neutral position to maximum dorsiflexion were measured. The tensile load of the Achilles tendon and ankle motion affected the contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus. The contact pressure increased with tensile load or ankle dorsiflexion. Conditions with increasing the tensile load of the Achilles tendon or under ankle dorsiflexion increase the contact pressure between the Achilles tendon and the posterosuperior prominence of the calcaneus.     

Assessment of the Resistance of Several Suture Techniques in Human Cadaver Achilles Tendons

Many treatments are available for acute Achilles tendon ruptures, conservative and surgical, with none superior to another. For surgical treatment, one can use various techniques. Recent studies have shown that double stitches are superior to simple sutures. Therefore, in the present study, we sought to determine the suture technique that is the most resistant to rupture. We performed an experimental anatomic study with 27 fresh-frozen human cadaveric Achilles tendons obtained through the body donation program of the University of Barcelona, testing the maximum strength. We simulated a rupture by performing resection in the middle portion of the tendon, 4 cm proximal to the calcaneus insertion. We then evaluated the double Kessler, double Bunnell, Krackow, and percutaneous Ma and Griffith technique. We used absorbable suture (polydioxanone no. 1) with all the techniques. Traction was performed using a machine that pulls the tendon at 10 to 100 N in 1000 repetitive cycles. Statistical analysis was performed using the χ² test and analysis of variance, with the 95% confidence intervals (p < .05). All repairs failed at the site of the suture knots, with none pulling out through the substance of the tendon. We found no significant differences among the different open suture techniques (p > .05). The Krackow suture presented with superior resistance, with a rupture rate 16.70% but with a mean elongation of 7.11 mm. The double Bunnell suture had the same rupture rate as the Krakow suture (16.70%) but with an inferior mean elongation of 4.53 mm. The Krackow and Bunnell suture were superior in endurance, strength of failure, and primary stability compared with the other suture types. However, the former presented with greater tendon elongation, although the difference was not statistically significant. Therefore, according to our findings and the published data, we recommend double Bunnell sutures for the surgical treatment of acute Achilles tendon rupture.     

Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series

Achilles tendinopathy is a clinical diagnosis characterized as a triad of symptoms including pain, swelling, and impaired performance of the diseased tendon. Achilles tendinopathy is divided into Achilles tendonitis and tendinosis based on histopathological examination. Achilles tendinosis is viewed microscopically as disorganized collagen, abnormal neovascularization, necrosis, and mucoid degeneration. Insertional Achilles tendinosis is a degenerative process of the tendon at the junction of the tendon and calcaneus. This disease is initially treated conservatively with activity modification, custom orthotic devices, heel lifts, and immobilization. After 3 to 6 months of conservative therapy has failed to alleviate symptoms, surgical management is indicated. Surgical management of insertional Achilles tendinosis includes Achilles tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision. In this case series, we present 4 patients who underwent surgical management of insertional Achilles tendinosis with complete tendon detachment. All patients underwent reattachment of the Achilles tendon with the suture bridge technique. The Arthrex SutureBridge^® (Arthrex, Inc., Naples, FL) device uses a series of 4 suture anchors and FiberWire^® (Arthrex Inc.) to reattach the Achilles tendon to its calcaneal insertion. This hourglass pattern of FiberWire^® provides a greater area of tendon compression, consequently allowing greater stability and possible earlier return to weightbearing activities. The patients were followed up for approximately 2 years’ duration. There were no intraoperative or postoperative complications. At final follow-up there was no evidence of Achilles tendon ruptures or device failures. All patients were able to return to their activities of daily living without the use of assistive devices. The patients’ average visual analog pain scale was 1 (range 0 to 4), and their average foot functional index score was 3.41 (range 0 to 10.71). The suture bridge technique is a viable option for Achilles tendon repair after surgical management of insertional Achilles tendinosis.