Ultrasound-guided Achilles tendon rupture repair using knotless barbed suture: a cadaveric study.

Category:Basic Sciences/Biologics; SportsIntroduction/Purpose:Achilles tendon ruptures cause long-term functional deficits in nearly 2 out of 3 patients. Our group has established a complex muscle-tendon pathology following isolated Achilles tendon ruptures. Our long-term goal is to determine how rehabilitation loads can simultaneously accomplish 2 competing objectives: (1) prevent muscle remodeling while (2) not overloading the healing tendon that causes permanent tendon elongation - unloading the muscle and stimulating muscle remodeling. To do this, we developed a novel experimental framework to test the potential therapeutic effectiveness of different loading paradigms on the healing muscle-tendon following surgically induced Achilles tendon ruptures in an established rat model. We hypothesized that overloading the healing tendon would lead to worse functional outcomes compared to unloaded immobilization.Methods:Achilles tendon rupture, repair, and immobilization. Male Sprague-Dawley rats underwent a surgically induced Achilles tendon rupture by blunt dissection followed by a modified Kessler repair in this IACUC approved study. The repaired limb was immobilized in either unloaded plantar flexion (n=7) to simulate the clinical standard of rehabilitative care or loaded dorsiflexion (n=5) to simulate clinically damaging rehabilitation. Structural analyses. Following 2 weeks of immobilization and 2 weeks of cage recovery, we sacrificed our study animals and measured tendon elongation and serial sarcomere count. Plantar flexor functional assessment. We developed an ankle dynamometer to quantify plantar flexor function that mirrored our clinical assessments in patients. To demonstrate the clinical- relevance of this device, we tested 1 animal that was immobilized in unloaded plantar flexion for 1 week and 1 animal that was immobilized in loaded dorsiflexion for 1 week - both then completed 2 weeks of unrestricted cage activity.Results:Muscle-tendon structural changes. Achilles tendon ruptures caused the tendon to heal in an elongated position with fewer sarcomeres in series (Fig. A). Tendon length increased by 73% following 2-weeks of loaded immobilization in dorsiflexion and 23% in unloaded immobilization in plantar flexion (p<.001). We measured sarcomere length in a subset of these animals but found similar trends in serial sarcomere reductions, where unloaded immobilization in plantar flexion caused 14% reduced serial sarcomeres (p<.01, n=4) and loaded immobilization in dorsiflexion caused 32% reduced serial sarcomeres (n=2). Plantar flexor function. Plantar flexor work was adversely impacted by the Achilles tendon ruptures (Fig. B). We found that unloaded immobilization in plantar flexion caused a 13% decrease in plantar flexor work with the detectable deficits occurring in ankle plantar flexion. Loaded immobilization in dorsiflexion caused greater plantar flexor work deficits (28%) with greater torque deficits in dorsiflexion and continuing through plantar flexion angles.Conclusion:Our exciting experimental findings are the first of their kind to directly link muscle-tendon structural deficits with plantar flexor functional deficits in an animal model of Achilles tendon rupture using a clinically relevant ankle dynamometer. We established preliminary evidence that supports our overarching hypothesis that joint immobilization, whether unloaded or loaded, causes detrimental muscle-tendon structural changes that impose functional constraints on plantar flexor work. Our preliminary findings suggest that rehabilitation loading is critical to structural and functional outcomes following surgically repairing the Achilles tendon. Too little loading promotes muscle remodeling while too much loading elongates the healing tendon.

Background: Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period. Hypothesis: Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: 75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9. Results: The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months. Conclusion: Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 (ClinicalTrials.gov identifier).

Category: Sports; Trauma Introduction/Purpose: Achilles Tendon (AT) rupture is one of the most prevalent adult tendon injuries, with the incidence rate estimated to range between 7 to 40 in 100000 person-years. Although some surgical approaches involve incising or removing the Paratenon when repairing injured or degenerative tendons, an alternative perspective suggests preserving the paratenon during AT repair could potentially benefit healing through two proposed mechanisms: retaining the hematoma, which may contain factors with stem cell-like properties and reducing mechanical stress on the skin incision site. The aim of this study was to investigate the potential influence of Paratenon preservation on the outcomes of AT repair in a 5-year follow up study. Methods: After receiving IRB approval, we conducted a single-center study in Tehran, Iran, involving a consecutive series of 52 patients who sustained acute AT ruptures (less than 2 weeks from injury) and underwent a modified surgical technique performed by surgeons affiliated with the local institution. The technique involved careful skin incision while preserving the Paratenon intact and performing the tendon repair over the retained Paratenon (Figure 1). Patients were prospectively evaluated with a mean follow-up duration of 5 years (between 48 to 72 months). Functional outcomes were assessed using the Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Society (AOFAS) rating scales in all patients at 6, 9, 18, and 36 months postoperatively. Two complementary follow-up visits at 12 and 24 months after the last visit were scheduled. Results: The mean AOFAS and ATRS scores were 83±4 and 85.7±3.1, respectively, by the 36-month follow-up visit. Approximately 90.1% of patients regained preinjury activity levels during the complementary follow-up visits, including 71.3% of professional athletes returning to prior recreation. Isokinetic testing revealed plantar flexion and dorsiflexion strength deficits of 83.7±5.1% and 87.8±3.6% compared to the uninjured sides at 3 months after the surgery. Calf muscle atrophy was minimal. While 19 patients reported initial activity-related pain, these symptoms resolved within 12 months. No wound complications, nerve injuries, or footwear issues occurred during the study period. Conclusion: Preserving the Paratenon during AT repair showed satisfactory functional and clinical outcomes without any case of the wound complications that are common after open repairs. These findings support the hypothesis that an intact Paratenon aids tendon healing and reduces complication rates. Retaining the Paratenon may also help mitigate the "bowstring" effect on the repaired Achilles tendon. This surgical technique warrants further investigation as a potential strategy for enhancing outcomes following AT ruptures.

Knotless barbed sutures are seeing more common use in wound closures and small tendon repairs. The purpose of this study was to evaluate the strength and resistance to gap formation of these sutures in larger tendons, such as the Achilles, compared with conventional repair. Six matched pairs of fresh-frozen human cadaver Achilles tendons were transected to simulate a rupture. Six tendons were repaired using a double Bunnell over-the-top technique with Fiberwire, and the matched pairs were repaired using a double Bunnell knotless technique with barbed suture. The tendons were tested to failure and stiffness, peak failure load, percentage elongation, load at initial gap and load at 5-mm gap (clinical failure) were compared. The mean peak failure load for the Fiberwire group (459 N) was significantly higher (P = .029) compared with the barbed suture group (184 N). Percentage elongation at peak load was significantly lower in the barbed suture group (P = .014), as was percentage elongation at initial gapping (P = .007) and percent elongation at 5 mm of gapping (P = .004). While the knotless barbed suture is attractive for its design and resistance to gap formation, low failure loads compared with conventional suture are concerning for large tendon repairs. Therapeutic, Level IV: Bench testing.

Introduction Currently,there is no consensus regarding optimal treatment options of Achilles tendon rupture. The purpose of this study was to evaluate long term results of Achilles tendon repair using different surgical techniques, assess complication rate and subjective satisfactionMethods The study included patients treated for Achilles tendon rupture using minimally invasive and open surgical repair. Complications including re-rupture, infection, deep vein thrombosis and neuropraxia were identified. In order to evaluate the factors influencing the risk of postoperative complications, logistic regression analysis was performed. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) evaluated subjective outcomes.Results 130 patients with Achilles tendon tear were enrolled (123 primary and 7 revision cases). In primary repairs percutaneous technique was used in 60 % of cases (74/123), mini open technique – in 16 % (19/123), and open technique – in 24 % (30/123). Re-rupture occurred in 2.4 % of patients treated with minimally invasive techniques. There were no repeated ruptures following open repairs. Predominant number of infections was registered after open repairs and made 10 %, while minimally invasive techniques had 3.2 % of infections. Logistic regression analyses showed that steroid injection, open repair, application of tapes and autografts increased the risk of infectious complications. There were no significant differences in ATRS and AOFAS scores between different primary Achilles tendon repair techniques (p &gt; 0.05).Discussion Results, obtained in the current study, are consistent with previously published data.Conclusions Open Achilles tendon repair showed a higher rate of infections, and lower rate of re-ruptures. The anamnesis of steroid injection, open repair, application of tapes and autografts increases the risk of infectious complications.

The structural and mechanical properties of the Achilles tendon 2 years after surgical repair

Background: Whether an Achilles tendon rupture is treated surgically or not, complications such as muscle weakness, decrease in heel-rise height, and gait abnormalities persist after injury. Purpose: The purpose of this study was to evaluate if side-to-side differences in maximal heel-rise height can be explained by differences in Achilles tendon length. Study Design: Case series; Level of evidence, 4. Method: Eight patients (mean [SD] age of 46 [13] years) with acute Achilles tendon rupture and 10 healthy subjects (mean [SD] age of 28 [8] years) were included in the study. Heel-rise height, Achilles tendon length, and patient-reported outcome were measured 3, 6, and 12 months after injury. Achilles tendon length was evaluated using motion analysis and ultrasound imaging. Results: The Achilles tendon length test-retest reliability (intraclass correlation coefficient = 0.97) was excellent. For the healthy subjects, there were no side-to-side differences in tendon length and heel-rise height. Patients with Achilles tendon ruptures had significant differences between the injured and uninjured side for both tendon length (mean [SD] difference, 2.6-3.1 [1.2-1.4] cm, P = .017-.028) and heel-rise height (mean [SD] difference, –4.1 to –6.1 [1.7-1.8] cm, P = .012-.028). There were significant negative correlations (r = −0.943, P = .002, and r = −0.738, P = .037) between the side-to-side difference in heel-rise height and Achilles tendon length at the 6- and 12-month evaluations, respectively. Conclusion: The side-to-side difference found in maximal heel-rise height can be explained by a difference in Achilles tendon length in patients recovering from an Achilles tendon rupture. Minimizing tendon elongation appears to be an important treatment goal when aiming for full return of function.

Background Some authors found that delayed repair of Achilles tendon ruptures achieved similar functional outcomes when compared with acute repair of Achilles tendon ruptures. The purpose of our study was to compare functional outcomes and complication rates of acute repair to delayed repair after Achilles tendon ruptures. Methods PubMed, Embase (Ovid) and the Cochrane Library were searched. Results For Achilles tendon rupture score (ATRS), the overall result revealed that there was no significant difference in ATRS between acute repair groups and delayed repair groups (P = 0.59). For Tegner scores, Halasi scores and Achilles tendon resting angle (ATRA), there was no significant difference between the two groups (P = 0.28, P = 0.47 and P = 0.68). There was no significant difference in the subjective assessment between acute repair groups and delayed repair groups (P = 0.84). However, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.01). Subgroup analyses showed that the mean time from injury to surgery of delayed repair groups affect the pooled result substantially. For mean time less than 28d, there was no difference in the incidence of complications between acute repair groups and delayed repair groups (P = 0.09). However, for mean time more than 28d, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.05). Conclusion Our study showed delayed repair could obtain similar functional outcomes and subjective assessment when compared with acute repair. However, the rate of complications after delayed repair was higher than that of early repair. Further high-quality randomized controlled trials (RCT) are needed to evaluate the difference.

Predictors of functional outcome in non-operatively managed Achilles tendon ruptures

Category: Hindfoot Introduction/Purpose: The optimal method of Achilles tendon repair remains undefined. Few previous studies have quantified the financial expenses of Achilles tendon repairs in relation to functional outcomes in order to assess the overall value of the accepted repair techniques. The purpose of this study is to demonstrate the value of supine positioning during open repair (OS) of acute Achilles tendon ruptures through the quantification of operative times, costs, and outcomes in comparison to the commonly performed percutaneous prone (PP) repair technique. Methods: A retrospective review was conducted on 67 patients undergoing OS and 67 patients undergoing PP primary Achilles tendon repair with two surgeons at four surgical locations. Total operating room usage times and operating times were collected from surgical site records. Total operating room times were used to estimate the costs of room usage and anesthesia, while costs of repair equipment were collected from the respective manufacturers. Patients undergoing OS repair completed the Foot and Ankle Ability Measure (FAAM) questionnaire, with activities of daily living (ADL) and sports subscales, Short Form-12 (SF-12), with mental (MCS) and physical (PCS) health subcategories, and the visual analog scale (VAS) for pain preoperatively and at final follow-up. Results: Even with a significantly longer mean surgical time (P=.035), OS repairs had a shorter duration of total operating room time when compared to that of PP repairs (58.4 versus 69.7 minutes, P&lt;.001). Estimated time-dependent costs were lower in OS repairs ($739 versus $861 per procedure, P&lt;.001), while the estimated average total per procedure cost was also lower for OS repairs ($801 versus $1,910 per procedure, P&lt;.001). For patients undergoing OS repair, FAAM-ADL (P&lt;.001), FAAM-Sports (P&lt;.001), SF-12-PCS (P&lt;.001) all increased and VAS grades (P&lt;0.001) decreased from time of initial encounter to final follow-up and were comparable to reported outcomes in the current literature. The complication rate in OS repairs (6.0%) was lower than PP repairs (11.9%), with revisions only occurring in the latter technique. Conclusion: Performing open Achilles tendon repair in the supine position offers substantial value, or “health outcomes achieved per dollar spent”, to providers due to decreased total operating room times and costs with satisfactory functional outcomes.

Category: Sports; Other Introduction/Purpose: Minimally invasive approaches to Achilles tendon (AT) repair have garnered significant attention due to their reported effectiveness. Due to the limited visibility of the tendon, a crucial factor for the success of these approaches lies in the precise targeting and adequate capture of the tendon substance. Insufficient tendon capture can lead to re-rupture or tendon elongation, potentially leading to poor patient-outcomes. Since many of the current techniques or devices for minimally invasive AT repair rely on needle passage through a single axial plane, it is imperative to understand the axial plane orientation of the AT along its course. This study aims to elucidate the axial plane position and width of the AT from its distal insertion to a level well above its common tear site. Methods: In this retrospective study, magnetic resonance imaging (MRIs) from 82 individuals (mean age: 38.7 years) with no history of AT pathology were reviewed from the foot and ankle registry of a single institution. Any patients with evidence of foot and ankle malalignment or those with poor quality MRIs were excluded from the study. Multiplanar reconstruction of the MRI images was performed to enable synchronized viewing of both the sagittal and axial planes of each MRI scan. Measurements were made to determine the axial axis of the AT at distances of 3, 5, 7, 9, and 11 cm from its insertion. These measurements were taken in relation to both the transmalleolar (TM) axis and the axis at the AT insertion (Figure 1). The width of the AT was also measured at these corresponding levels. Results: The average rotation of the AT across all measurement levels showed an external rotation relative to the TM axis (Figure 2). The least rotation was observed at the 3cm level (2.1 degrees), while the maximum rotation was seen at both the 7cm and 9cm levels (11.2 degrees). There was a pattern where the AT showed an increasing external rotation as it extended proximally from 3cm to 9cm from its insertion. Between 5 cm and 7 cm from the insertion, there was a shift in the tendon's orientation (p&lt;.0001), transitioning from internal to external rotation (Figure 2). Moreover, a noticeable reduction in the width of the AT was observed between the 5 cm and 7 cm measurement levels, distinct from the other levels. Conclusion: The rotational profile of the AT observed in this study indicates the need for caution regarding possible external rotation of the AT, especially when targeting its proximal portion using a minimally invasive approach, compared to its distal part. The considerable variations in AT orientations across different individuals underscore the potential benefits of using intraoperative assistive techniques such as ultrasonography to determine individual rotational profiles. Furthermore, the noted narrower width and rotational differences between the 5 cm and 7 cm levels could explain the frequent instances of AT ruptures within this specific range.

Permanent loss of muscle function seen after an Achilles tendon rupture may partly be explained by tendon elongation and accompanying shortening of the muscle. Muscle fascicle length shortens, serial sarcomere number is reduced, and the sarcomere length is unchanged after Achilles tendon transection (ATT), and these changes are mitigated with suturing. The method involved in this study was a controlled laboratory study. Two groups of rats underwent ATT on one side with a contralateral control (CTRL): A) ATT with 3 mm removal of the Achilles tendon and no suturing (substantial tendon elongation), and B) ATT with suture repair (minimal tendon elongation). The operated limb was immobilized for 2 wk to reduce load. Four weeks after surgery the rats were euthanized, and hindlimbs were analyzed for tendon length, gastrocnemius medialis (GM) muscle mass, length, fascicle length, sarcomere number and length. No differences were observed between the groups, and in both groups the Achilles tendon length was longer (15.2%, P < 0.001), GM muscle mass was smaller (17.5%, P < 0.001), and muscle length was shorter (8.2%, P < 0.001) on the ATT compared with CTRL side. GM fascicle length was shorter (11.2%, P < 0.001), and sarcomere number was lower (13.8%, P < 0.001) on the ATT side in all regions. Sarcomere length was greater in the proximal (5.8%, P < 0.001) and mid (4.2%, P = 0.003), but not distal region on the ATT side. In this animal model, regardless of suturing, ATT resulted in tendon elongation, loss of muscle mass and length, and reduced serial sarcomere number, which resulted in an "overshoot" lengthening of the sarcomeres.NEW & NOTEWORTHY Following acute Achilles tendon rupture, patients are often left with functional deficits. The specific reason remains largely unknown. The shortened muscle leads to reduced fascicle length, in turn leading to adaptation by reduced serial sarcomere numbers. Surprisingly, this adaptation appears to "overshoot" and lead to increased sarcomere length. The present animal model advances understanding of how muscle sarcomeres, which are difficult to measure in humans, are affected when undue elongation takes place after tendon rupture.

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The Krackow locking loop technique has been used for Achilles tendon repair with documented success in allowing early range of motion with stable fixation. Previous studies documented failure at the rupture site by knot failure. We propose a modification of the traditional Krackow technique where the knots of the suture are tied away from the rupture site (aka the Giftbox technique). We compared the tensile strength of Achilles tendons repaired using the traditional Krackow technique with those repaired using the Giftbox technique. Thirteen pairs of fresh frozen cadaveric Achilles tendons were harvested. An Achilles tendon rupture was created 4 cm from the calcaneal insertion. Thirteen Achilles ruptures were repaired using the traditional Krackow technique and 13 pairs were repaired using the Giftbox technique. The Achilles tendons were then tested to failure as defined as a gap of 1 cm. The mean force to failure for the tendons using the Giftbox technique was 168 N, whereas the mean for the traditional Krackow technique was 81 N (p < 0.0001). Based on our biomechanical study, Achilles tendons repaired using the Giftbox technique are more than twice as strong as those repaired using the traditional Krackow technique. We recommend the Giftbox modification to minimize gap formation and improve the strength of the repair of a ruptured Achilles tendon.

Category:Sports; OtherIntroduction/Purpose:Achilles tendon ruptures are a common sporting injury, mostly occurring in men over the age of 40. Operative repair of Achilles tendon can lead to earlier return to activity and improved function in the active population. Mini-open repairs have recently been described for effective treatment of Achilles tendon ruptures. We aim to describe our unique mini- open Achilles tendon repair technique and to report our clinical outcomes.Methods:We retrospectively reviewed charts of patients from January 2010 and July 2019 who underwent a 3cm mini-open Achilles tendon repairs, without additional targeting devices, for closed acute Achilles tendon ruptures. Patients were followed up for a minimum of one year. We recorded pre- and postoperative Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS) scores. Subgroup analysis were performed for acute repairs (< 2 weeks) and subacute (2-6 weeks). Two-sided student’s t-test to compare preoperative and postoperative outcomes for continuous variables. Chi-square analyses were used to determine the strength of correlation between categorical variables. A p-value of < .05 was considered significant for all statistical analyses.Results:A total of 33 patients met the inclusion criteria and are included in this study. The mean age of our cohort was 43.8 years old (range 22-78) and 78.8% of patients were male. The mean length of follow-up was 4.4 years (range 1.0-9.8 years). The mean time from injury to surgery was 15.6 days (1-45 days). Patients reported a mean return to their previous level of activity at a mean of 5.6 months (range 1.7-22.1). The mean pre- and postoperative outcomes scores improved significantly for both the acute and subacute repair groups (p < 0.05). There were no significant differences for postoperative outcomes scores between the acute and subacute Achilles repair groups (p > 0.05). There were no reported complications in our patient cohort.Conclusion:Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There were no significant difference in outcomes for acute versus subacute repairs. Our mini-open Achilles tendon repair, which required no additional targeting instrumentation, has shown favorable mid-term results.