Review of Achilles Tendon Reattachment Using Double-Row Knotted and Knotless Techniques in the Management of Insertional Achilles Tendinopathy

Single-Row Repair Versus Double-Row Repair in the Surgical Management of Achilles Insertional Tendinopathy: A Systematic Review

Background

Approximately 6% of people will report Achilles tendon pain during their lifetime, and one-third of these individuals will have Achilles insertional tendinopathy (AIT). For patients who have failed conservative treatment, surgical repair is performed. Achilles tendon repair can occur through various techniques, including a single-row or double-row repair.

Purpose

To determine if there are significant advantages to double-row repair over single-row repair with respect to biomechanical and clinical outcomes.

Study design

Systematic review; Level of evidence, 3.

Methods

A systematic review of the literature was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search of the EMBASE and PubMed databases was performed for all studies related to surgical treatment of AIT, which yielded 1431 unique results. These included both biomechanical and clinical studies. Clinical studies in which patients were not diagnosed with AIT, underwent surgery for repair of acute Achilles tendon rupture, or studies that included additional procedures such as a concomitant flexor hallucis longus transfer were excluded. Eligible studies were independently screened by 2 reviewers. A risk-of-bias assessment was conducted using the Cochrane Risk Of Bias In Non-randomized Studies-of Interventions and risk-of-bias tool for randomized trials tools.

Results

A total of 23 studies were included, 4 of which were biomechanical studies and 19 were clinical studies. Biomechanical comparison found that there was a significant advantage to using double-row versus single-row fixation with respect to load at yield (354.7 N vs 198.7 N; P = .01) and mean peak load (433.9 N vs 212 N; P = .042). There was no significant difference between double-row and single-row repair with respect to load to failure. Significant heterogeneity of the studies did not allow for a statistical comparison of the clinical outcomes between double-row and single-row repairs.

Conclusion

Although biomechanical studies favor double-row repair for AIT, the current data available on the clinical outcomes are not sufficient to determine if there is a clinical advantage of double-row repair. Larger, prospective randomized controlled trials utilizing validated outcome measures are needed to further elucidate whether the biomechanical advantages associated with double-row repair also translate into improved patient-reported outcomes.

Double-Row Achilles Insertional Repair With Rip-Stop Increases Construct Strength Compared to Traditional Techniques: A Biomechanical Study

BACKGROUND

Although double-row suture-anchored (DRSA) techniques for Achilles insertional tendinosis has proven successful, a reoccurring failure mode not yet addressed is suture tearing through the tendon. This study aims to address suture tearing by incorporating a rip-stop element. Authors hypothesized that the Rip-Stop group would demonstrate increased strength compared with more traditional techniques.

METHODS

12 paired cadaveric feet were used in this study (n = 24). One sample from each pair was assigned to receive the standard double-row (SDR) Achilles repair with 4.75-mm knotless anchors (n = 12). The control's matched sides were divided between 2 DRSA bridge groups: modified double-row (MDR) bridge with 3.9-mm anchors or rip-stop double-row (RS-DR) bridge repair with soft proximal anchors and 3.9-mm anchored distal row. In neutral position, specimens underwent 1000 cycles (20-100 N) followed by load to failure. Displacements, stiffness, ultimate load, and failure mode were recorded.

RESULTS

RS-DR had the lowest initial displacement values followed by SDR and MDR (1.3 ± 0.4, 2.7 ± 1.4, and 3.2 ± 1.3 mm, respectively). Significance was detected when comparing initial displacement of RS-DR to MDR (P = .038). Cyclic displacement was lowest for RS-DR, followed by MDR and SDR (1.6 ± 0.9, 2.2 ± 1.1, and 4.5 ± 3.2 mm, respectively). Cyclic stiffness was similar for RS-DR and MDR (89.1 ± 24.6 and 81.9 ± 5.6 N/mm, respectively). RS-DR ultimate load (1116.8 ± 405.7 N) was statistically greater than SDR (465.6 ± 352.7, P = .003).

CONCLUSION

RS-DR-repaired specimens demonstrated a decrease in displacement values and increased ultimate load and stiffness when compared to other groups. Results of this cadaveric model suggest that the addition of a rip-stop to DRSA Achilles repair is more impactful than anchor size. Limitations include that this was a time-zero biomechanical study, which cannot simulate the performance of the repairs during postoperative healing and recovery.

CLINICAL RELEVANCE

A rip-stop technique for Achilles repair effectively improves dynamic mechanical characteristics and may mitigate suture tearing through tendon in a patient cohort.

Comparison between achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional achilles tendinopathy: A meta-analysis

BACKGROUND

The debridement and Achilles tendon reinsertion (DATR) have been the most common surgical approach for the treatment of Insertional Achilles Tendinopathy (IAT), while dorsal closing wedge calcaneal osteotomy (DCWCO) has recently gained popularity as an alternative surgical option. This study aimed to systematically review the published literature on both surgical techniques and compare their clinical outcomes and complication rates.

METHODS

A systematic review was performed according to the PRISMA guidelines using Medline, Embase, and Scopus databases. The inclusion criteria encompassed clinical studies reporting functional outcomes and complications, with a minimum of 10 patients and at least 12 months of follow-up.

RESULTS

Seven studies (n = 169) were included for the analysis of DATR, and eight studies (n = 227) were included for the analysis of open DCWCO. Both groups showed a similar improvement in AOFAS score. The overall complication rates were 16.6% in the DATR group and 9.2% in the DCWCO group, but the difference was not statistically significant. However, there was a significantly higher incidence of wound complications in the DATR group (10.1%, 95% C.I.: 4.7-15.6) compared to the DCWCO group (2.5%, 95% C.I.: 0.6-4.4) as the confidence intervals did not overlap.

CONCLUSIONS

Clinical outcomes and overall complication rates of both techniques were comparable, although DCWCO had a lower incidence of wound complications. Further research should be focused on prospective studies comparing the two techniques to corroborate the current findings.

LEVEL OF EVIDENCE

Level IV; meta-analysis.

Treatment of Calcific Insertional Achilles Tendinopathy: Knotless Internal Brace versus Knot-Tying Suture Bridge

Background: This study aimed to compare the knotless internal brace technique and the knot-tying suture bridge technique via the medial approach in the treatment of calcific Achilles tendinopathy. Methods: The clinical data of 25 cases of calcific Achilles tendinopathy in which nonoperative treatments had failed were retrospectively collected. All the patients received Achilles tendon debridement and Haglund deformity excision through a medial approach, followed by repair using the knotless internal brace technique or the knot-tying suture bridge technique. Pain was evaluated by using the visual analog scale (VAS). The American Orthopedic Foot and Ankle Score (AOFAS) questionnaire was administered preoperatively and postoperatively. Results: The mean follow-up time was 2.6 (range 2–3.5) years. There were no wound complications and no Achilles tendon ruptures. At 1 year postoperatively, the internal brace group was superior to the suture bridge group in terms of the VAS scores (p = 0.003). However, no differences were noticed between the two groups in either the VAS or the AOFAS scores at 2 years postoperatively. Conclusions: The medial approach in combination with the suture bridge technique was effective in treating calcific Achilles tendinopathy. The knotless internal brace technique involved less pain compared to the knot-tying suture bridge technique only at the early postoperative stage.