Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears

All-inside endoscopic semiautomatic running locked stitch technique shows favourable outcomes for acute Achilles tendon ruptures

PURPOSE

The safety and reliability of endoscopic Achilles tendon rupture repair are still concerning aspects. This study's aim is to evaluate an all-inside endoscopic semiautomatic running locked stitch (Endo-SARLS) technique.

METHODS

Forty cases with acute Achilles tendon rupture were treated with the all-inside Endo-SARLS technique between 2020 and 2021. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semiautomatic flexible suture passer. The threads of the high-strength suture were grasped through the paratenon subspace and then fixed into calcaneal insertion with a knotless anchor. Magnetic resonance imaging (MRI), surgical time and complications were assessed. Achilles Tendon Total Rupture Score (ATRS), Achilles Tendon Resting Angle (ATRA) and Heel Rise Height Scale (HRHS) were utilised to evaluate final outcomes.

RESULTS

The average follow-up time was 25.4 ± 0.4 (range: 24-32) months. Appropriate tendon regeneration was observed on MRI after 12 months. At the final follow-up, the median value of ATRS score was 95 (interquartile range: 94, 98). Furthermore, there is no significant difference between the injured and contralateral side in the average ATRA (18.2 ± 1.8 vs. 18.3 ± 1.9°, ns) and median value of HRHS [14.5 (13.3, 15.5) vs. 14.8 (13.5, 15.6) cm, ns]. No infection and nerve injuries were encountered. Thirty-nine patients reported that they resumed casual sports activity after 6 months. One patient had a slight anchor cut-out, due to an addition injury, which was removed after 5 months.

CONCLUSIONS

An all-inside Endo-SARLS technique showed promising clinical results for acute Achilles tendon ruptures. This procedure reduces the risk of sural nerve injuries while establishing a reliable connection between the tendon stumps.

LEVEL OF EVIDENCE

Level IV.

Are Prospective Criteria or Objective Clinical Measures Utilized in Return to Play (RTP) Decision Making After Ankle Surgery? A Scoping Review

Background

Manuscripts discussing return to play (RTP) following ankle surgery are common. However, the definition for RTP and the method by which it is determined remains unclear. The purpose of this scoping review was to clarify how RTP is defined following ankle surgery in physically active patients, to identify key factors informing RTP decision making (such as objective clinical measures), and make recommendations for future research.

Methods

A scoping literature review was performed in April 2021 using PubMed, EMBASE, and Nursing and Allied Health databases. Thirty studies met inclusion criteria: original research following ankle surgery reporting at least 1 objective clinical test and documentation of RTP. Data were extracted for study methods and outcomes (RTP definition, RTP outcomes, and objective clinical tests).

Results

The scoping review found studies on 5 ankle pathologies: Achilles tendon rupture, chronic lateral ankle instability, anterior ankle impingement, peroneal tendon dislocation, and ankle fracture. RTP criteria were not provided in the majority of studies (18/30 studies). In the studies that provided them, the RTP criteria were primarily based on time postsurgery (8/12) rather than validated criteria. Objective clinical outcome measures and patient-reported outcome measures (PROMs) were documented for each surgery when available. Both clinical outcomes and PROMs were typically measured >1 year postsurgery.

Conclusion

In physically active patients who have had ankle surgery, RTP remains largely undefined and is not consistently based on prospective objective criteria nor PROMS. We recommend standardization of RTP terminology, adoption of prospective criteria for both clinical measures and PROMs to guide RTP decision making, and enhanced reporting of patient data at the time of RTP to develop normative values and determine when the decision to RTP is not safe.

Level of Evidence

Level IV, scoping review.

Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review

Persistent muscle weakness, tendon elongation, and incomplete return to preinjury level are frequent sequelae after acute Achilles tendon rupture, and evidence-based knowledge of how to best rehabilitate the injury is largely absent in the literature. The objective of this review is to illuminate and discuss to what extent an Achilles tendon rupture affects muscle, tendon, and function when assessed with the Achilles tendon total rupture score (ATRS), muscle strength, muscle cross-sectional area, tendon length, and the heel-rise test. The patient-reported outcome measures (PROM) data in the literature suggest that the recovery takes longer than 6 months (ATRS, 70 out of 100), that one-year postinjury, the ATRS only reaches 82, and that this does not appear to noticeably improve thereafter. Loss of muscle mass, strength, and function can in some cases be permanent. Over the first 6 months postinjury, the tendon undergoes elongation, which appears to be negatively correlated to heel-rise function. More recently, there has been some interest in how muscle length and excursion is related to the reduced function. The available literature indicates that further research is highly warranted and that efforts to restore normal tendon length may improve the likelihood of returning to preinjury level after an Achilles tendon rupture.

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture

BACKGROUND

Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our "traditional" or a "slowed down" rehabilitation after percutaneous surgical repair.

METHODS

Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated.

RESULTS

At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one.

CONCLUSION

Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Midterm functional performance following open surgical repair of acute Achilles tendon rupture

INTRODUCTION

Various impairments such as soleus atrophy and consecutive functional deficits in end-range plantarflexion have been described in surgical repair of acute Achilles tendon rupture. The aim of this study was to assess the functional performance at midterm following open surgical repair.

MATERIALS AND METHODS

This cross-sectional study includes n = 52 patients which were tested on average 3.5 ± 1.4 years postoperatively using three different functional performance tests and patient-reported outcome measures. Two different surgical techniques (anatomical repair = AR vs. conventional repair = CR) were compared in a subanalysis. The testing included isokinetic strength testing, a novel setup of heel-rise testing using a marker-based 3D motion analysis system and a gait analysis.

RESULTS

At an average 3.5 years post-surgery, there is a persisting deficit in plantarflexion strength of 10.2%. Moreover, analysis of maximum peak torque angle and strength deficits according to the plantarflexion angle revealed that these deficits are not equally distributed across the range of motion. AR results in a significantly smaller deficit at 10° of plantarflexion compared to CR (13.9 vs. 29.9%, p < 0.05). This reflects into the functional performance during different modalities (static vs. dynamic) in this novel method of heel-rise testing.

CONCLUSION

In summary, there are persisting functional deficits at > 3 years following Achilles tendon repair which range from strength deficits to specific impairments of functional performance e.g. during heel rise. Anatomical reconstruction is associated with an improved functional performance potentially due to a more symmetric strength during end-range plantarflexion which transfers into a higher satisfaction during athletic activities.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Comparison of mini-open repair system and percutaneous repair for acute Achilles tendon rupture

Background

To reduce incision complications, minimally invasive operative approaches for treatment with acute Achilles tendon rupture have been developed, such as Mini-open repair and percutaneous repair. Which technique is the better surgical option? In the present study, we compared the two surgical procedures— modified Mini-open repair versus percutaneous repair—in the treatment of acute Achilles tendon rupture.

Methods

From January 2016 to November 2018, 68 matched patients with acute Achilles tendon rupture were divided into treatment group (Mini-open with modified Ma-Griffith technique) and control group (the Ma–Griffith technique). The patients were then treated with different surgical techniques and followed up for no less than 24 months, and the functional outcome scores and complications were retrospectively evaluated.

Results

The mean follow-up time in Mini-open repair group was 29.0±2.9 months, and that in control group was 27.9±2.9 months (P=0.147). The Mini-open repair group showed reliably higher American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Achilles tendon Total Rupture Score (ATRS) than the control group in functional assessment (95.0±3.8 vs. 92.3±5.3, P=0.000; 93.8±3.8 vs. 90.9±4.5,P=0.000). There was no cases of sural nerve injury in Mini-open repair group, whereas the percutaneous repair group had 5 cases of the same (P=0.027). No significant differences were found in the calf circumference (32.3±3.9 vs. 31.8±3.6) (P=0.564), range of motion of the ankle (51.3±4.8 vs. 50.5±4.2, P=0.362), or wound complications (34/0 vs. 34/0) (P=1.000) between the two groups at the end of the follow-up time. However, the percutaneous repair group had a shorter average operating time (23.1±5.2 min) than that of the Mini-open repair group (27.7±4.3 min) (P=0.000).

Conclusions

Acute Achilles tendon ruptures may be treated successfully with a new Mini-open repair system or percutaneous repair technique. However, the Mini-open repair system may represent a superior surgical option, since it offers advantages in terms of direct visual control of the repair, AOFAS Ankle-Hindfoot Score, Achilles tendon Total Rupture Score and risk of sural nerve palsy.

Study design

Case-control studies, Level of evidence, 3.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04802-8.

Endoscopic "internal splinting" repair technique for acute Achilles tendon rupture

INTRODUCTION

Recently, endoscopically assisted Achilles tendon repair techniques have improved to overcome the surgical complications. However, the risk of sural nerve injury and the strength of repair are still the most concerning aspects.

MATERIAL AND METHODS

Twenty three patients with acute Achilles tendon rupture were reviewed in the present study. We stitch the Achilles tendon above the ruptured site using the endoscopic locking loop suture technique, and the knotless anchor suture-bridge technique can be used to make the distal fixation of threads. The function was assessed using the muscle power (MRC0-5), ATRS scores, AOFAS ankle-hindfoot scores, and VAS scores at the final follow-up.

RESULTS

The mean follow-up time was 15.74 ± 2.43 months (12-18). At the final follow-up, the average of the muscle power (MRC0-5), ATRS score, AOFAS ankle-hindfoot score, and VAS score are 4.74 ± 0.45, 97.83 ± 2.77, 96.52 ± 4.87, and 0.35 ± 0.49, respectively. Every patient returned to previous sports activity at 6 months postoperative. No wound infection and sural nerve injuries were encountered. Only one case suffers local irritation at the medial knotless anchor site.

CONCLUSIONS

Endoscopic "internal splinting" repair for acute Achilles tendon rupture using locking loop stitch with suture-bridge technique leads to an expedited return to activity with a low risk of complications.

LEVEL OF EVIDENCE

Level IV, case series.

Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study

INTRODUCTION

Despite the presence of various different surgical procedures, the preferable technique for repair of acute Achilles tendon ruptures is unknown and, therefore, object of discussions. The purpose of this meta-analysis was to compare clinical outcomes and complication-rates between the minimally invasive and the standard open repair of acute Achilles tendon ruptures.

MATERIALS AND METHODS

This meta-analysis was performed according to the PRISMA guidelines. In September 2019 the main databases were accessed. All clinical trials of evidence level I to III comparing minimally invasive vs. open surgery of Achilles tendon rupture were included in the present study. Only articles reporting quantitative data under the outcomes of interest were included. Missing data under the outcomes of interest warranted the exclusion from the present work. For the statistical analysis we referred to the Review Manager Software Version 5.3. (The Nordic Cochrane Centre, Copenhagen). Continuous data were analysed through the inverse variance method. For the effect estimate the mean difference was used. Dichotomous data were analysed through the Mante-Haenszel method via odd ratio effect measure. The confidence interval was set at 95% in all the comparisons. Values of P < 0.05 were considered statistically significant.

RESULTS

A total of 25 articles were included for meta-analysis. The funnel plot revealed poor data dispersion, attesting to this study a low risk of publication bias. The quality of the methodological assessment was moderate. Data from 2223 (1055 open, 1168 minimally invasive) surgical procedures were extracted. The mean follow-up was of 24.29 ± 22.4 months. The open group reported a lower value of post-operative palpable knot at last follow-up and a lower rate of sural nerve palsy. In the minimally-invasive group a shorter surgery duration and a lower rate of post-operative wound necrosis and reduced risk of wound scarring and adhesions has been evidenced. The minimally-invasive cohort detected the lowest values of superficial and deep infections. In both groups no significant difference was shown in re-rupture rate.

CONCLUSIONS

Compared to the minimally-invasive Achilles tendon reconstruction, the open procedure evidenced a lower rate of sural nerve palsy and postoperative palpable knot, whereas in the minimally-invasive reconstruction group quicker surgery duration, a lower rate of post-operative wound necrosis, superficial and deep infections and less scar tissue adhesions could be observed. No relevant discrepancies were detected among the two techniques in terms of post-operative re-rupture.

Association of Strength Following Achilles Tendon Repair With Return to Same Level of Play in High-Level Athletes

BACKGROUND

Rupture of the Achilles tendon is a common injury and the ability to return to the same level of sporting activity after treatment is an important outcome for patients. The objective of the current study was to examine the relationship between ankle strength and the ability to return to previous level of play following operative repair of an Achilles tendon rupture.

METHODS

Patients aged 18 to 50 years at a minimum 1 year postoperation from surgical repair of an Achilles tendon returned for a study visit. Patients reported both preinjury and current activity level using the 10-point Tegner Activity Level Scale. Isokinetic strength testing was performed and the Isokinetic Strength Score (ISS) was calculated. Logistic regression analysis was used to determine the relationship between ISS and return to play by Tegner level. A total of 36 patients (mean 35 years old, 72% male) completed the study protocol at a mean 1.8 years postoperatively.

RESULTS

Logistic regression revealed no association between ISS and return to play in the complete cohort. Subgroup analysis revealed that for 20 high-level athletes (preinjury Tegner ≥ 7), for every 16-point increase in ISS, the odds ratio (OR) for return to same level of play was 8.3 (P = .055) and the OR for return to within 1 Tegner level of play was 6.3 (P = .043). There was no association between ISS and return to previous activity in the 16 patients with lower preinjury levels of activity.

CONCLUSION

Improved ankle strength was associated with return to previous level of activity in patients participating in high-level athletic activity, suggesting that these patients were more dependent on recovery of ankle strength in the postoperative time period in order to return to their previous high level of play. In contrast, regaining strength may be less important for returning to normal activities for less active patients.

LEVEL OF EVIDENCE

Level III, comparative series.

Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review

Background:

Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines.

Purpose:

To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture.

Results:

A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53).

Conclusion:

Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.