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.     

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.     

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.     

Achilles Tendon Reconstruction With Bone Block Allograft:Long-Term Follow-Up of Two Cases

The treatment of neglected or chronically ruptured Achilles tendon is challenging. Various treatments for large defects associated with chronic Achilles ruptures have been described. Many surgeons recommend the use of a tendon transfer, turndown rotational flap, advancement flap, or reconstruction with Achilles tendon allograft with calcaneal bone block. Long-term outcomes of these procedures are unknown. We present 2 cases with the use of an Achilles tendon with calcaneus bone block allograft. At >8-year follow-up duration, both patients are afforded satisfactory levels of activity and are without pain or gait disturbance. This procedure is a viable option for Achilles ruptures with large defects, ruptures with small intact distal tendon portions, or re-ruptures of previously repaired Achilles tendons. The long-term outcomes of these case reports suggest that Achilles tendon reconstruction with bone block allograft is a viable option.     

Editorial Commentary: Suture Type or Technique Has Little Influence on Outcome After Acute Lower-Extremity Tendon Rupture

Operative repair of Achilles tendon rupture significantly decreases the rerupture rate, regardless of type of surgical suture technique. Likewise, regarding repair of either the quadriceps or patellar tendon, surgical repair technique does not significantly influence the generally excellent outcomes achieved, whereas too-early mobilization should be avoided. In terms of the use of suture versus suture tape, load to failure is similar. Many factors impact tendon rupture repair success, including postoperative care, the quality of the tendon, underlying medical issues, and patient compliance, but suture type or technique has little influence on outcome after acute lower-extremity tendon rupture.     

Tendon injuries about the ankle resulting from skiing

In essence there are three afflictions about the ankle that result from skiing: rupture of the Achilles tendon, Achilles tendinitis, and dislocation of the peroneal tendon. The cause of Achilles tendinitis and Achilles tendon rupture is, in fact, pressure within the fascial compartment of the Achilles tendon, which is caused by a swollen distal soleus muscle, occluding the circulation, and thereby producing avascular necrosis with subsequent tendinitis yielding to rupture. Four types of peroneal tendon dislocations and related problems are presented.     

Reconstruction of a Neglected Achilles Tendon Rupture With an Achilles Tendon Allograft: A Case Report

Multiple surgical techniques for repair of neglected Achilles tendon ruptures have been described in the literature. The authors present a case using a freeze-dried Achilles tendon allograft for repair of a neglected rupture of the Achilles tendon with a defect of 10 cm. At 1-year follow-up, the patient achieved pre-injury functional use of the affected limb.     

Results of Achilles Tendon Excision for Purpose of Wound Closure: Case Series

The loss of Achilles tendon results in reduced plantar flexion strength; however, in patients who are not fit for major reconstructive surgery, with soft-tissue defects overlying the tendon, Achilles tendon excision is a useful adjunct procedure for wound closure. We report 3 patients with infections around the Achilles tendons needing debridement procedures who underwent Achilles tendon excision for the purpose of wound closure. Local healing was achieved in all patients; all returned to their premorbid ambulatory status, and 2 could perform heel raise. Our series showed that Achilles tendon excision eases soft-tissue reconstruction around it and that the primary aim of wound closure was met with a reasonable functional outcome. As such, it is a viable option for selected patients with infections around the Achilles tendon who are poor candidates for flaps.     

应用同种异体肌腱加强修复治疗陈旧性跟腱断裂

目的探讨同种异体肌腱加强修复治疗陈旧性跟腱断裂的临床疗效。方法2005年1月至2011年12月,对26例陈旧性跟腱断裂患者,采用同种异体肌腱在跟腱断裂两侧的正常跟腱组织冠状面钻孔环扎,加强修复断裂的跟腱。结果26例均获随访9～52个月,平均30．7个月,除1例术后伤口延迟愈合外,其余伤口均I期愈合,无全身或局部不良反应,无跟腱黏连再手术者,无跟腱再断裂发生。采用Arner—Lindholm疗效评定方法,优22例（84．6％）,良4例（15．4％）。结论同种异体肌腱加强修复治疗陈旧性跟腱断裂疗效满意,并发症少,手术操作简单,是一种可行的手术方法。     

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.     

Percutaneous Repair Technique for Acute Achilles Tendon Rupture with Assistance of Kirschner Wire

The aim of this study is to introduce a self‐designed, minimally invasive technique for repairing an acute Achilles tendon rupture percutaneously. Comparing with the traditional open repair, the new technique provides obvious advantages of minimized operation‐related lesions, fewer wound complications as well as a higher healing rate. However, a percutaneous technique without direct vision may be criticized by its insufficient anastomosis of Achilles tendon and may also lead to the lengthening of the Achilles tendon and a reduction in the strength of the gastrocnemius. To address the potential problems, we have improved our technique using a percutaneous Kirschner wire leverage process before suturing, which can effectively recover the length of the Achilles tendon and ensure the broken ends are in tight contact. With this improvement in technique, we have great confidence that it will become the treatment of choice for acute Achilles tendon ruptures.     

Endoscopic-Assisted Achilles Tendon Repair With Plantaris Tendon Augmentation

Six portals are made at the sides of the Achilles tendon. The plantaris tendon is harvested and retrieved to the distal-medial portal. The investing fascia of the Achilles tendon is released at the medial border of the tendon. The suture is passed through the tendon end through the medial portal and exits at the tendon surface and then the fascia and skin. The suture is retrieved at the tendon surface through the medial portal. The loops of the suture are retrieved through the proximal-medial, proximal-lateral, and lateral portals, and a loop of suture is then formed at the surface of the tendon and beyond the boundary of the tendon. The suture is passed through the tendon again in a deep-to-superficial direction within the loop and is retrieved through the proximal-medial portal. The suture is tensioned, and a locking stitch is formed. The loops of the suture are retrieved through the medial, lateral, and proximal-lateral portals. The suture is then passed through the tendon in a deep-to-superficial direction and is retrieved again through the proximal-medial portal, and the second locking stitch is formed. This is repeated 3 to 4 times over the medial side of the proximal tendon through the proximal-medial portal, and the suture is then passed to the proximal-lateral portal at the surface of the tendon. Locking stitches are then applied to the lateral side of the tendon. The same procedure is then repeated over the distal tendon with another suture. The tendon ends are approximated with the pair of sutures tied through the medial and lateral portals. The plantaris tendon is passed through the Achilles tendon with a pointed tendon passer through the proximal and distal portals. The plantaris tendon is then looped around the Achilles tendon and sutured to it.     

An Uncomplicated Method for Minimally Invasive Achilles Tendon Repair

The Achilles tendon is the largest palpable tendon in the human body, and rupture of this tendon is not an uncommon injury encountered by foot and ankle surgeons. A number of different minimally invasive methods have been described for repair of the ruptured Achilles tendon. In this article, we describe a relatively simple, minimally invasive technique of Achilles tendon repair that does not require special instrumentation, the key requirement being that of a sponge forceps.     

Modified Lateral Position for Achilles Tendon Surgeries: A Technical Tip

Most Achilles tendon surgeries are performed with the patient in the prone position. Some advocate supine position but the access to the tendon is compromised. We describe an innovative technique wherein the patient is positioned lateral but the surgeon has full access to the Achilles tendon as if the patient were positioned prone. We consider that this technique could be easily reproduced and hence widely adopted.     

吻合血管大收肌肌腱游离移植修复跟腱缺损的初步报告

目的 为跟腱缺损修复提供一种新的有效手术方法。方法 通过对４２侧下肢标本解剖、观测大收肌肌腱的形态和供血的来源、走行和分布情况,设计了吻合膝降血管的大收肌肌腱游离移植修复跟腱缺损的术式。临床应用１０例,其中陈旧性跟腿缺损８例,跟腱伴皮肤缺损２例,分别采用吻合血管的大收肌肌腱和大收肌肌腱－皮瓣游离移植修复。结果 全部病例随访２～８个月,Ｔｈｏｍｐｓｏｎ征阴性１０例,双足提踵试验阴性１０例,单足提踵试     

Augmented Repair of Acute Total Achilles Tendon Rupture With Peroneus Brevis Tendon Transfer Using Oblique Transosseous Calcaneal Tunnel: A Prospective Case Series

Acute Achilles tendon rupture is one of the most common tendon injuries. This prospective study aimed to evaluate the functional outcomes of augmented repair of acute Achilles tendon rupture with peroneus brevis tendon transfer and fixation to an oblique calcaneal transosseous tunnel. Functional evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS). Postoperative complications were recorded. This study included 33 males and 9 females, with a mean age of 26.1 ± 4.2 years. The Achilles tendon ruptures were right in 24 patients and left in 18 patients. The cause of rupture was sports injuries in all patients. The mean distance from the calcaneal insertion to the tear site was 4.4 ± 1.3 cm. The mean time from injury to surgery was 2.4 ± 1.6 days. The mean follow-up time was 40.3 ± 4.9 months. The mean AOFAS and ATRS scores were 99.3 ± 1.2 and 95.9 ± 1.9, respectively, at 12 months of follow-up. The mean time to return to work was 12.1 ± 1.2 weeks. The mean time to return to light sports activities was 16.1 ± 1.8 weeks postoperatively. None of the patients developed re-rupture. Augmented repair of acute Achilles tendon ruptures with peroneus brevis tendon transfer is a robust repair with excellent functional outcomes and early weight-bearing and return to sports activities.     

Atraumatic Spontaneous Achilles Tendon Rupture in Patients Receiving Oral Corticosteroids Treated With the Modified Side-Locking Loop Suture Technique

Atraumatic spontaneous Achilles tendon ruptures sometimes occur in patients receiving oral corticosteroids. In general, these cases are treated surgically; however, delayed postoperative management can lead to impaired activities of daily living. The modified side-locking loop suture (SLLS) technique is a useful suture method for safe and early active mobilization. Three cases of spontaneous Achilles tendon ruptures were treated with the modified SLLS technique with good clinical results. The modified SLLS technique is a useful method with a short rehabilitation period for treating atraumatic spontaneous Achilles tendon rupture in patients undergoing corticosteroid therapy.     

Correlation between the Coaptation and Regeneration of Tendon Stumps in Endoscopic Assisted Achilles Tendon Rupture Repair

Objective

When the endoscopic Achilles tendon repair technique is utilized, direct stitching of the ruptured site is challenging due to the frayed tendon stumps. To explore whether undesirable coaptation of the tendon stumps influences the generation of the tendons.

Methods

This study is a retrospective analysis of 46 patients who underwent a modified endoscopic Achilles tendon rupture repair from October 2018 to June 2020. Patients were divided into two groups according to the coaptation of tendon stumps on postoperative ultrasonography. Group 1 included 17 cases with undesirable coaptation (<50%), and Group 2 included 29 cases with appropriate coaptation (≥50%). Magnetic resonance imaging (MRI) was obtained postoperatively at 3, 6, and 12 months to evaluate the tendon morphological construction. Clinical evaluations were performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, the Achilles Tendon Total Rupture Score (ATRS), muscle power, and the Achilles tendon resting angle at the final follow-up. Complications were also encountered. The Student's t-test and the Mann–Whitney U-test were used to assess differences among both groups.

Results

The mean follow-up time was 37.5 ± 10.6 months in Group 1 and 39.0 ± 11.6 months in Group 2, respectively. The average age in Group 1 is slightly older than in Group 2 (37.3 ± 6.1 vs. 32.7 ± 6.3, p = 0.021). The tendon cross-section areas and thickness increased initially and decreased later on postoperative MRI evaluation. It also showed a significantly higher signal/noise quotient (SNQ) in Group 1 at postoperative 3 months. At postoperative 6 and 12 months, the SNQ between both groups was similar. The AOFAS score (95.9 ± 5.1 vs. 96.2 ± 4.9, p = 0.832), ATRS score (97.0 ± 3.6 vs. 97.7 ± 3.3, p = 0.527), and muscle power (21.38 vs. 24.74, p = 0.287) were not significantly different between both groups. However, the resting angle of Group 1 was significantly larger than that of Group 2 (4.6 ± 2.4 vs. 2.4 ± 2.3, p = 0.004). There was no difference in the complications (p = 0.628).

Conclusion

Although complete regeneration can be finally achieved, the early stage of tendon stump regeneration can be prolonged due to undesirable coaptation when endoscopic Achilles tendon repair technique is applied. The prolonged high signal duration on MRI indicates the less-than-ideal regeneration of the tendon, which might lead to elongation of the tendon.     

Interference Screw Fixation for Flexor Hallucis Longus Tendon Transfer for Chronic Achilles Tendonopathy

Chronic Achilles tendinosis can be a challenging problem to the foot and ankle surgeon. Multiple surgical treatment options have been described for this condition including transfer of the Flexor Hallucis Longus (FHL) tendon for an incompetent Achilles tendon. Our technique describes FHL tendon transfer into the calcaneus to replace or supplement the Achilles tendon using a single posterior incision, a "short harvest" and interference screw fixation.     

Anterior Cruciate Ligament Reconstruction: A New Technique for Achilles Tendon Allograft Preparation

We describe a new technique in Achilles tendon allograft preparation for use in anterior cruciate ligament (ACL) reconstruction that allows for secure bony interference fixation on each side of the joint and aperture fixation for all patients. In addition, preparation of the graft in this manner avoids some problems that are frequently encountered with patellar tendon allografts, including graft tunnel mismatch and limited availability. Previous studies have reported successful results with Achilles tendon allograft use in ACL reconstruction with soft tissue fixation in the tibial tunnel. Bony interference fixation on the tibial side can be achieved by suturing a free bone plug to the tendon end of an Achilles allograft. We use a 9-mm circular oscillating saw to harvest a free 30-mm length bone plug from the remaining calcaneal bone block. This is then sutured directly to the tendon end of a bone-Achilles tendon allograft with the use of No. 1 nonabsorbable suture placed through 3 equally spaced drill holes in the free bone plug. Tendon length between the bone plugs can be individually set for each patient at a distance equivalent to the length of the native ACL (intra-articular distance between the femoral and tibial tunnels). After graft passage, the construct is tensioned and secured with interference screws, similar to a traditional bone–patellar tendon–bone graft. The senior author (S.G.) has performed 40 procedures with excellent results and reports no cases of tibial fixation failure. Biomechanical and long-term follow-up studies are in progress.