Evaluation of a New Knotless Suture Anchor Repair in Acute Achilles Tendon Ruptures: A Biomechanical Comparison of Three Techniques

Acute ruptures of the Achilles tendon are a common injury, and debate has continued in published studies on how best to treat these injuries. Specifically, controversy exists regarding the surgical approaches for Achilles tendon repair when one considers percutaneous versus open repair. The present study investigated the biomechanical strength of 3 different techniques for Achilles tendon repair in a cadaveric model. A total of 36 specimens were divided into 3 groups, each of which received a different construct. The first group received a traditional Krackow suture repair, the second group was repaired using a jig-assisted percutaneous suture, and the third group received a repair using a jig-assisted percutaneous repair modified with suture anchors placed into the calcaneus. The specimens were tested with cyclical loading and to ultimate failure. Cyclical loading showed a trend toward a stronger repair with the use of suture anchors after 10 cycles (p = .295), 500 cycles (p = .120), and 1000 cycles (p = .040). The ultimate load to failure was greatest in the group repaired with the modified knotless technique using the suture anchors (p = .098). The results of the present study show a clear trend toward a stronger construct in Achilles repair using a knotless suture anchor technique, which might translate to a faster return to activity and be more resistant to an early and aggressive rehabilitation protocol. Further clinical studies are warranted to evaluate this technique in a patient population.     

Operative Treatment of Acute Achilles Tendon Rupture: Open End-to-End-Reconstruction Versus Reconstruction with Mitek-Anchors

Purpose: To retrospectively compare the open end-to-end repair versus repair using the Mitek-anchor system in acute Achilles tendon rupture.

Method: Forty-seven consecutive patients with Achilles tendon rupture, all operated on between 2004 and 2005, were included. Their medical records were reviewed and they were interviewed for surveillance of post-operative function at follow-up. Functional outcome was determined using an adapted VISA tendinopathy questionnaire and by testing the isometric ankle plantar flexion strength. Post-operative complications and recurrence rate of rupture were noted. Results: Seven patients were lost to follow-up. From a total of 40 patients, twenty-eight (68% of total) underwent classic repair and 12 (32%) were treated by the Mitek-anchor system. Median age was 43 years (range 29–63). Median post-operative follow-up was 29 months (range 17–40). Median time to resume work was nine weeks in the classic group versus 12 weeks in the Mitek-group. Median time to resume sports was 19 versus 31 weeks respectively. Wound infections occurred in five percent of the total (one in each group) and rupture recurrence rate was three percent of the total (nil in classic group, one in Mitek-group). Loss of strength in the injured leg compared to the non-injured leg was greater in the Mitek-group than in the classic group.

Conclusion: We conclude that in comparing classical end-to-end repair of acute Achilles tendon ruptures with repair using Mitek-anchors, it took patients in the Mitek-group longer to return to work and sport activities than in the classic group. Greater loss of strength in the injured leg was seen in the Mitek-group. Therefore we do not advocate the use of Mitek-anchors for the repair of acute ruptured Achilles tendons.     

Kinetic and Kinematic Evaluation of the Ankle Joint After Achilles Tendon Reconstruction With Free Semitendinosus Tendon Graft: Preliminary Results

Chronic rupture of the Achilles tendon (AT) is a surgical challenge and has effects on the gait. The purpose of this study was to evaluate the kinetic and kinematic parameters of the ankle joint in patients with AT rupture operated using a free semitendinosus tendon graft. Thirteen patients were analyzed 6 and 12 months after surgery in a force platform, while the movements were recorded by six infrared cameras. The kinematic variables analyzed included speed, cadence, step length, percentage of stance phase, and range of movement (ROM) of the ankle joint in the sagittal and frontal planes. Kinetic data were obtained by joint movement in different phases of the gait cycle. Functional assessment was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) score. The patients showed a significant increase (P = 0.0215) in AOFAS from 68.5 (±18.7) to 85.2 (±18.0). Speed, cadence, and length of step of the four groups (1A, 1B, 2A, 2B) were lower than the control group (group 3), and the percentage in stance phase was higher for the nonoperated foot 6‐month group (1B) compared to the control group (group 3). For the kinematic data, the ROM of the ankle in stance phase increased from 6 to 12 months showing an effect of time between four groups (1A, 1B, 2A, 2B). During swing phase, the ankle ROM was lower in the operated side (effect of side, P = 0.0255) and groups 1A and 2A demonstrated statistical differences when compared with the control group (group 3) (P = 0.0240 and P = 0.0414, respectively). ROM of inversion and eversion presented effect of time among the same groups (P = 0.0059) cited before. There were no differences in kinetic data between groups. This study showed close proximity between the control group and the operated group. Furthermore, improvement was shown when comparing the 6 and 12 months postsurgery periods. The surgical procedure is therefore helpful for the patient and few changes were present in gait and ankle biomechanics.     

A Wound Complication After Percutaneous Achilles Tendon Lengthening Requiring Surgical Excision: A Case Report

A percutaneous tendo-Achilles lengthening procedure corrects limited ankle joint equinus by decreasing the pull of the triceps surae complex. The standard technique using 3-incision hemisection described by Hoke is often used in patients with diabetes because of the minimal number of incisions and low risk of wound complications. We describe a patient who underwent percutaneous tendo-Achilles lengthening with a resultant open wound complication requiring staged surgical debridement.     

Calcific Insertional Achilles Tendinopathy-Achilles Repair With Flexor Hallucis Longus Tendon Transfer: Case Series and Surgical Technique

Calcific insertional Achilles tendinopathy (CIAT) is a relatively common musculoskeletal entity that results in significant pain and disability, as well as posterior muscle group weakness. There is a lack of evidence criteria to support the timing of operative intervention, choice of procedures, or whether equinus requires treatment. The purpose of this study was to retrospectively review 45 patients (48 feet) who have undergone surgical management of CIAT with concomitant posterior muscle group weakness with the single heel rise testing. All patients underwent debridement and repair of the Achilles tendon with reattachment of the Achilles tendon to the calcaneus, ostectomy of the calcaneus, and flexor hallucis longus tendon transfer. Those patients with equinus also underwent gastrocnemius recession. The focus includes patient-reported satisfaction, time to return to normal shoe gear, and the incidence of revision surgery. The overall average of time to weightbearing was 4.3 weeks. After surgery, 73.3% (n?=?33) of the 45 patients responded to the following question: “Would you have this surgery done again?” Of these patients, 93.9% (n?=?31) responded “Yes” and 6.1% (n?=?2) responded “Unsure.” Of the same 33 patients, 84.8% (n?=?28) responded that they were “Very Satisfied” with the procedure and 15.2% (n?=?5) responded that they were “Satisfied.” Twelve patients (26.7%) did not respond to either question. One of the 12 patients (8.3%) who did not respond had bilateral procedures. None of the patients experienced tendon rupture, deep vein thrombosis, or the need for revision surgery. Four patients (8%) experienced a superficial infection, whereas 1 patient (2%) had development of a deep infection. No correlations were found when looking at the relationship between body mass index and return to weightbearing/normal shoe gear with Spearman analysis.     

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.     

Surgical Versus Non-Surgical Methods for Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Controlled Trials

We performed a meta-analysis to (1) compare surgical and non-surgical treatment methods for repair of acute rupture of the Achilles tendon, in terms of the re-rupture rate, incidence of complications other than re-rupture, functional outcomes, and proportion of patients returning to previous levels of sporting activities, and (2) explore the difference in the re-rupture rate if proven early functional rehabilitation protocols were followed.PubMed, EMBASE, Medline, and Cochrane Central Register of Controlled Trials databases were searched to identify randomized clinical trials. The quality of included studies was assessed by the Cochrane risk-of-bias tool. The random-effects model or subgroup analysis would be chosen to perform the meta-analysis if the data were heterogeneous; otherwise, the fixed-effect model would be selected.Ten randomized clinical trials with a total of 934 randomized patients were included. Patients in the non-surgical group underwent higher re-ruptures than patients in the surgical group (p?=?.0002), but the re-rupture rates were equivalent in the non-surgical group and the surgical group (p?=?.08) if an early range of motion exercises protocol was performed. Lower incidence of complications excluding re-rupture was found in non-surgical patients (p?=?.006). However, the surgical group had better results in functional outcomes when evaluated by 2 different jump tests (drop counter-movement jump [p?=?.002], Hopping [p?=?.004]) and 1 muscular endurance test (Heel-rise work [p?=?.01]). The 2 groups had no significant difference in the proportion of patients returning to previous levels of sporting activities (p?=?0.87).The risk of re-rupture after surgical or non-surgical treatment was equivalent if a functional rehabilitation protocol with early range of motion was performed, but the risk of other complications happening after surgical treatment was higher than in non-surgical treatment.     

Achilles Tendon Augmented Repair Using Human Acellular Dermal Matrix: A Case Series

Achilles tendon ruptures are common in the general population, especially among members of the older demographic occasionally active in sports. Operative treatments provide a lower incidence of rerupture than do nonoperative treatments, although surgical complications remain a concern. The use of a human acellular dermal matrix to augment Achilles tendon repair might reduce the incidence of complications. In the present case series, we describe the outcomes of 9 patients who underwent Achilles tendon repair with acellular dermal matrix augmentation. Functional outcomes were evaluated using the Foot Function Index-Revised long form, and the clinical results were recorded. After a mean average follow-up period of 14.4 (range 12.0 to 20.0) months, the mean Foot Function Index-Revised long form score was 33.0%?±?4.2%. No cases of rerupture or complications that required additional treatment occurred during the observation period. The outcomes we have presented support further evaluation beyond this case series for using a human acellular dermal matrix to augment Achilles tendon repairs.     

Ankle Fracture Associated With Rupture of the Achilles Tendon: Case Report and Review of the Literature

Solitary ankle fracture or Achilles Tendon (AT) rupture might not be an uncommon injury. However, concomitant ipsilateral ankle fracture with AT rupture is rare. The present report discusses this rare combination. A 30-year-old female had fallen while rock climbing and sustained a closed fracture of the medial malleolus with an ipsilateral complete AT rupture. Most of the reported cases had similar patterns, not only in terms of history, but also in terms of a similar fracture pattern. This rare combination of orthopedic injuries tends to occur when an abrupt excessive force is applied to the forefoot, with subsequent ankle hyperextension or hindfoot inversion. Imaging studies are useful both for confirming the injuries and for medicolegal and research purposes. Definitive treatment of the AT rupture is usually surgical in young active patients. Concomitant malleolar fractures can be managed conservatively or surgically, depending on the fracture configuration and degree of displacement. The importance of a thorough clinical examination in assessing the musculoskeletal and neurovascular structures in ankle injuries cannot be overemphasized. Knowledge of these injury patterns is crucial to reducing the incidence of residual morbidity such as ankle and foot weakness and loss of motion.     

Surgical versus nonsurgical treatment of acute Achilles ruptures in the high demand patient: Using decision analysis to help clinical decisions

BackgroundRecent literature suggests that functional treatment of acute non-insertional Achilles tendon ruptures yields outcomes (re-rupture and function) similar to those of surgery, but does not address the unique issues in treating high performance athletes or other high demand patients.MethodsDecision analysis was used to develop an estimate of outcome utility for both types of treatment using published Costs and Quality-Adjusted Life Years (QALYs) values. The expected value for either treatment was then calculated for high, intermediate, and normal demand patients, using the specific functional needs of the patients.ResultsNonoperative treatment is the preferred management for normal demand patients, while high and intermediate demand patients are more likely to experience better expected functional outcomes from surgery.ConclusionThe combination of a decision analysis and expected value analysis provides evidence-based support for the existing intuitive recommendations that favor surgical treatment in elite athletes and other high demand patients.Level of EvidenceIII