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Chuckpaiwong B, Glisson RR, Usuelli FG, Madi NS, Easley ME. Biomechanical Comparison of Nonlocked Minimally Invasive and Locked Open Achilles Tendon Simulated Rupture Repairs. Foot Ankle Int 2023; 44:913-921. [PMID: 37329183 DOI: 10.1177/10711007231178819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Open repair of Achilles tendon ruptures is associated with a risk of infection and other wound complications. Although percutaneous repairs reduce these complications, they may increase the risk of nerve injury. This study was designed to determine whether a percutaneous nonlocking repair can approach the gapping resistance offered by a standard open repair under conditions approximating typical postoperative physiotherapy. METHODS Ten pairs of cadavers Achilles tendons were transected in situ 5 cm above the insertion. One tendon from each pair was repaired using an open 4-strand Krackow locking loop, and the contralateral tendon was repaired with the Achillon system using the same suture material. Displacement transducers were attached to the medial, lateral, anterior, and posterior aspects of the tendon, spanning the repair. Each tendon underwent 1000 tensile loading cycles to 86.5 N, simulating passive ankle range-of-motion physiotherapy. Gapping was documented on the 1st, 50th, 100th, 500th, and 1000th cycles. The ultimate tensile strength of each repaired tendon was then measured by distracting until gross failure occurred. RESULTS Gapping of the percutaneous repairs exceeded that of conventional open repairs on the first, 500th, and 1000th load cycles. All 10 conventionally repaired tendons withstood 1000 load cycles without gross failure, but 4 of 10 percutaneous minimally invasive repairs failed, one on the 9th load cycle and the others between the 100th and 500th cycles. On average, tendons repaired with the open technique withstood 66% greater tensile load in failure testing than those repaired with the percutaneous technique. CONCLUSION Open Krackow Achilles tendon repairs may better withstand more aggressive postoperative physiotherapy than nonlocked percutaneous repairs. CLINICAL RELEVANCE The study suggests that surgeons should consider locking suture approaches to avoid loss of repair integrity with early motion.
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Affiliation(s)
- Bavornrit Chuckpaiwong
- Department of Orthopaedic Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Richard R Glisson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Naji S Madi
- Department of Orthopaedic Surgery, West Virginia University, Morgantown, WV, USA
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Devereux S, Jack M, Worth A, Bridges J. Calcaneotibial screws for immobilisation of the tarsocrural joint of dogs in extension: effect of the angle of screw placement on the force to failure in a canine cadaveric model. N Z Vet J 2021; 69:294-298. [PMID: 34013827 DOI: 10.1080/00480169.2021.1931522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS To compare the force to failure under axial loading of a calcaneotibial screw placed approximately perpendicular to the tibia with that of a screw placed perpendicular to the calcaneus, when used to immobilise the tarsus in an ex vivo canine model. METHODS Twelve pairs of cadaveric hindlimbs from large breed dogs, without orthopaedic or soft tissue disease, were prepared by transecting the limb at the level of the stifle and stripping the limbs of all musculature from the stifle to mid-metatarsus, including removal of the common calcaneal tendon from all limbs. The limbs in each pair were randomly assigned to receive a calcaneotibial screw placed perpendicular to the long axis of either the calcaneus (C group) or the tibia (T group) with the tarsus in full extension. The distal limb was potted in resin and the proximal tibia was pinned to allow biomechanical testing in compressive loading. Testing was performed to apply an axial load using a material testing machine in a proximodistal direction through the tibia, advancing at a rate of 10 mm/second. The force to failure was recorded in kN and compared between groups. RESULTS The median force to failure of the C group was 0.86 (min 0.50; max 1.64) kN which was higher than the T group which had a median force to failure of 0.74 (min 0.26, max1.05) kN (p = 0.004). All modes of failure were by screw pull-out. CONCLUSIONS A calcaneotibial screw placed at an angle approximately perpendicular to the long axis of the calcaneus, has a higher force to failure under axial loading than a calcaneotibial screw that is placed at an angle approximately perpendicular to the tibia, in a canine cadaveric model. CLINICAL RELEVANCE A temporary calcaneotibial screw is a common method of immobilising the tarsus in extension to protect primary repair of a common calcaneal tendon injury. Placing a calcaneotibial screw perpendicular to the calcaneus may be a more reliable option for immobilisation of the tarsus to protect a common calcaneal tendon repair compared to screws placed perpendicular to the tibia. However extrapolation of these results into a clinical setting requires caution.
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Affiliation(s)
- S Devereux
- Massey University Veterinary Teaching Hospital, School of Veterinary science, Massey University, Palmerston North, New Zealand
| | - M Jack
- Cave Veterinary Specialists, Wellington, UK
| | - A Worth
- Massey University Veterinary Teaching Hospital, School of Veterinary science, Massey University, Palmerston North, New Zealand
| | - J Bridges
- Massey University Veterinary Teaching Hospital, School of Veterinary science, Massey University, Palmerston North, New Zealand
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Resistance Exercises in Early Functional Rehabilitation for Achilles Tendon Ruptures Are Poorly Described: A Scoping Review. J Orthop Sports Phys Ther 2020; 50:681-690. [PMID: 33094667 PMCID: PMC8168134 DOI: 10.2519/jospt.2020.9463] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To (1) describe which resistance exercises are used in the first 8 weeks of treatment for acute Achilles tendon rupture and (2) assess the completeness of reporting of the exercise descriptions. DESIGN Scoping review. LITERATURE SEARCH We searched the MEDLINE, Embase, CINAHL, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases. STUDY SELECTION CRITERIA Randomized controlled trials, cohort studies, and case series (10 or more participants) that reported using resistance exercise in the immobilization period in the first 8 weeks of treatment for acute Achilles tendon rupture were included. DATA SYNTHESIS Completeness of exercise description was assessed with the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier exercise descriptor framework. RESULTS Thirty-eight studies were included. Fifty-one resistance exercises were extracted and categorized as isometric exercises (n = 20), heel raises (n = 6), strengthening with external resistance (n = 13), or unspecified (n = 12). A median of 8 (interquartile range, 6-10) of a possible 19 CERT items was reported. The amount of items described of the 13 Toigo and and Boutellier exercise descriptors ranged from 0 to 11. CONCLUSION A variety of resistance exercises targeted at the ankle plantar flexors were used as part of early functional rehabilitation after Achilles tendon rupture. However, most studies provided inadequate description of resistance exercise interventions. J Orthop Sports Phys Ther 2020;50(12):681-691. Epub 23 Oct 2020. doi:10.2519/jospt.2020.9463.
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Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG. Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119884071. [PMID: 31803789 PMCID: PMC6878623 DOI: 10.1177/2325967119884071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer A Zellers
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marianne Christensen
- Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark.,Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Inge Lunding Kjær
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
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De la Fuente CI, Lillo RPY, Ramirez-Campillo R, Ortega-Auriol P, Delgado M, Alvarez-Ruf J, Carreño G. Medial Gastrocnemius Myotendinous Junction Displacement and Plantar-Flexion Strength in Patients Treated With Immediate Rehabilitation After Achilles Tendon Repair. J Athl Train 2016; 51:1013-1021. [PMID: 27922288 DOI: 10.4085/1062-6050-51.12.23] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT Pathologic plantar flexion frequently occurs after operative repair of the Achilles tendon (AT) because of immobilization and non-weight bearing in the first weeks of traditional rehabilitation. Novel rehabilitation strategies that apply mobilization and weight bearing have been proposed, but their effects on medial gastrocnemius myotendinous junction displacement (MJD) and isometric plantar-flexion strength (PFS) are unknown. OBJECTIVE To compare the effects of 12 weeks of immediate versus traditional rehabilitation on MJD and PFS in patients with percutaneous AT repair and to compare AT rupture scores (ATRSs) during follow-up. DESIGN Controlled laboratory study. SETTING Human performance laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 26 amateur soccer players (age = 42.3 ± 9.7 years, body mass index = 29.5 ± 3.9 kg/m2) with percutaneous AT repair. INTERVENTION(S) Athletes were randomly divided into 2 groups: an immediate group, given physical therapy from day 1 to day 84, and a traditional group, given physical therapy from day 29 to day 84. We used repeated-measures analysis of variance to compare the data. MAIN OUTCOME MEASURE(S) We measured MJD and PFS at days 28 (fourth week), 56 (eighth week), and 84 (12th week) after AT repair. RESULTS After 12 weeks of rehabilitation, we observed a large clinically meaningful effect and statistical difference between groups. At day 28, the immediate group showed higher values for PFS (P = .002), MJD (P = .02), and ATRS (P = .002) than the traditional group. At day 56, the immediate group presented higher values for MJD (P = .02) and ATRS (P = .009). At day 84, the immediate group registered more MJD (P = .001). CONCLUSIONS Compared with traditional rehabilitation, 12 weeks of immediate rehabilitation after percutaneous AT repair resulted in better MJD, PFS, and ATRS after 4 weeks; better MJD and ATRS after 8 weeks; and better MJD after 12 weeks.
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Affiliation(s)
- Carlos I De la Fuente
- Carrera de kinesiología, UDA Cs de la salud, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago.,Facultad Cs de la Rehabilitacion, Universidad Andres Bello, Santiago, Chile
| | | | | | | | - Mauricio Delgado
- Carrera de kinesiología, UDA Cs de la salud, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Joel Alvarez-Ruf
- Universidad Metropolitana de ciencias de la Educación, Santiago, Chile
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Dogramaci Y, Duman IG. Reinforcement of the Flexor Tendon Repair Using Human Amniotic Membrane A Biomechanical Evaluation Using the Modified Kessler Method of Tendon Repair. J Am Podiatr Med Assoc 2016; 106:319-322. [PMID: 27762620 DOI: 10.7547/15-036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Human amniotic membrane is used to prevent peritendinous adhesions after tendon injuries. This study compares the mechanical properties of modified Kessler repairs and modified Kessler repairs strengthened using multiple layers of human amniotic membrane. METHODS Twenty flexor digitorum profundus tendons of sheep forelimbs were sutured by the two-strand modified Kessler technique (group A) and by the two-strand modified Kessler repair reinforced with multiple layers of human amniotic membrane (group B). To assess the mechanical performance of the repairs, tendons were subjected to a linear noncyclic load-to-failure test using a material testing machine. Outcome measures included ultimate forces and the mode of failure. RESULTS The mean ± SD value of the failure strength was 34.6 ± 1.64 N for group A and 50.6 ± 5.60 N for group B. The reinforced repair provided a significantly higher ultimate load compared with the nonreinforced group (P < .001). All of the specimens failed due to suture breakage at the repair site. CONCLUSIONS The results of this study show that the modified Kessler repair can be reinforced effectively with human amniotic membrane.
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Affiliation(s)
- Yunus Dogramaci
- Department of Orthopaedics and Trauma Surgery, Mustafa Kemal University, Faculty of Medicine, Hatay, Turkey
| | - Ibrahim Gökhan Duman
- Department of Orthopaedics and Trauma Surgery, Mustafa Kemal University, Faculty of Medicine, Hatay, Turkey
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Abstract
UNLABELLED The efficient and effective function of the Achilles tendon is essential for normal gait and sporting performance. The optimal technique for the operative repair of the Achilles midsubstance rupture remains controversial. Suboptimal outcomes are common even after successful Achilles repair. Factors contributing to poor outcomes include a tenuous soft tissue envelope (leading to wound complications, peritendinous adhesions, and poor tendon healing,) as well as failure to maintain appropriate musculotendinous length, even after successful repair.We present a new technique using the InternalBrace (IB) and a modification of the Percutaneous Achilles Repair System (PARS; Arthrex Inc, Naples, FL), the Achilles Mid-Substance Speed Bridge Repair. This IB approach is knotless, respects the soft tissue envelope, and allows the appropriate musculotendinous length to be set intraoperatively. The IB principle enables direct fixation to bone allowing early mobilization while minimizing the risk of knot slippage, accelerating recovery, and allowing for restoration of normal function. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- James R McWilliam
- New York Medical College, Valhalla, NY, USA Specialty Orthopaedics, PLLC, Harrison, NY, USA
| | - Gordon Mackay
- University of Stirling, Scotland, United Kingdom The MacKay Clinic, Ltd., Scotland, United Kingdom
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Jielile J, Aibai M, Sabirhazi G, Shawutali N, Tangkejie W, Badelhan A, Nuerduola Y, Satewalede T, Buranbai D, Hunapia B, Jialihasi A, Bai J, Kizaibek M. Active Achilles tendon kinesitherapy accelerates Achilles tendon repair by promoting neurite regeneration. Neural Regen Res 2014; 7:2801-10. [PMID: 25317130 PMCID: PMC4190862 DOI: 10.3969/j.issn.1673-5374.2012.35.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 11/04/2012] [Indexed: 01/09/2023] Open
Abstract
Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7–21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy.
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Affiliation(s)
- Jiasharete Jielile
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Minawa Aibai
- Urumqi Center for Disease Control and Prevention, Urumqi 830026, Xinjiang Uyghur Autonomous Region, China
| | - Gulnur Sabirhazi
- Xinjiang Institute of Ecology and Geography, Chinese Academy of Sciences, Urumqi 830011, Xinjiang Uyghur Autonomous Region, China
| | - Nuerai Shawutali
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Wulanbai Tangkejie
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Aynaz Badelhan
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Yeermike Nuerduola
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Turde Satewalede
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Darehan Buranbai
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Beicen Hunapia
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Ayidaer Jialihasi
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Jingping Bai
- Department of Orthopedics, Third Teaching Hospital of Xinjiang Medical University, Urumqi 830011, Xinjiang Uyghur Autonomous Region, China
| | - Murat Kizaibek
- The Research Institute of Kazakh Traditional Medicine of Ili Kazakh Autonomous Prefecture of Xinjiang, Yining 835000, Ili Kazakh Autonomous Prefecture of Xinjiang, China
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Prevention of peritendinous adhesions using an electrospun DegraPol polymer tube: a histological, ultrasonographic, and biomechanical study in rabbits. BIOMED RESEARCH INTERNATIONAL 2014; 2014:656240. [PMID: 25101292 PMCID: PMC4101979 DOI: 10.1155/2014/656240] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/23/2014] [Accepted: 06/02/2014] [Indexed: 11/17/2022]
Abstract
Purpose. One of the great challenges in surgical tendon rupture repair is to minimize peritendinous adhesions. In order to reduce adhesion formation, a physical barrier was applied to a sutured rabbit Achilles tendon, with two different immobilization protocols used postoperatively. Methods. Thirty New Zealand white rabbits received a laceration on the Achilles tendon, sutured with a 4-strand Becker suture, and half of the rabbits got a DegraPol tube at the repair site. While fifteen rabbits had their treated hind leg in a 180° stretched position during 6 weeks (adhesion provoking immobilization), the other fifteen rabbits were recasted with a 150° position after 3 weeks (adhesion inhibiting immobilization). Adhesion extent was analysed macroscopically, via ultrasound and histology. Inflammation was determined histologically. Biomechanical properties were analysed. Results. Application of a DegraPol tube reduced adhesion formation by approximately 20%—independently of the immobilization protocol. Biomechanical properties of extracted specimen were not affected by the tube application. There was no serious inflammatory reaction towards the implant material. Conclusions. Implantation of a DegraPol tube tightly set around a sutured tendon acts as a beneficial physical barrier and prevents adhesion formation significantly—without affecting the tendon healing process.
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Adams SB, Thorpe MA, Parks BG, Aghazarian G, Allen E, Schon LC. Stem cell-bearing suture improves Achilles tendon healing in a rat model. Foot Ankle Int 2014; 35:293-9. [PMID: 24403347 DOI: 10.1177/1071100713519078] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tendon healing is a slow and complicated process that results in inferior structural and functional properties when compared to healthy tendon tissue. It may be possible to improve outcomes of tendon healing with enhancement of biological aspects of the repair including tissue structure, organization, and composition. The purpose of this study was to determine whether use of a stem cell-bearing suture improves Achilles tendon healing in a rat model. METHODS The Achilles tendon was transected in 108 bilateral hind limbs from 54 rats. Each limb was randomized to repair with suture only (SO), suture plus injection (SI) of mesenchymal stem cells (MSCs) at the repair site, or suture loaded with MSCs (suture with stem cells, SCS). One half of the animals were randomly sacrificed at 14 and 28 days after surgery and the Achilles tendon was harvested. From each repair group at each time point, 12 limbs were randomized to biomechanical testing and 6 to histologic analysis. Tendons were loaded using a 223-N load cell at 0.17 mm/s. A blinded pathologist scored the histology sections. RESULTS Ultimate failure strength (N/mm(2)) was significantly higher in the SI and SCS groups versus the SO group. In the SI group, ultimate failure strength decreased significantly at 28 days versus 14 days. Histology score in the SCS group was significantly lower (better) than in both other groups (P ≤ .001). Histology findings at day 28 were significantly higher versus day 14 for all groups (P = .01). CONCLUSIONS Both the SI and the SCS groups had significantly higher ultimate failure strength versus the SO group, and strength was maintained at 28 days in the SCS group but not in the SI group. Histology in the SCS group was significantly better than in both other groups. CLINICAL RELEVANCE These findings in a rat model suggest that the use of stem cells enhances healing after Achilles repair and that embedding of stem cells directly into suture offers sustained early benefit to tendon healing.
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Affiliation(s)
- Samuel B Adams
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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11
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Fanter NJ, Davis EW, Baker CL. Fixation of the Achilles tendon insertion using suture button technology. Am J Sports Med 2012; 40:2085-91. [PMID: 22802272 DOI: 10.1177/0363546512453294] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the operative treatment of Achilles insertional tendinopathy, no guidelines exist concerning which form of fixation of the Achilles tendon insertion is superior. HYPOTHESIS Transcalcaneal drill pin passage does not place any major plantar structures at risk, and the addition of a Krackow stitch and suture button to the fixation technique provides a significant increase in ultimate load to failure in Achilles tendon insertional repairs. STUDY DESIGN Controlled laboratory study. METHODS The Achilles tendon insertions in 6 fresh-frozen cadaveric ankles were detached, and transcalcaneal drill pins were passed. Plantar dissection took place to evaluate the drill pin relationship to the plantar fascia, lateral plantar nerve and artery, flexor digitorum longus tendon, and master knot of Henry. The Achilles tendons were then repaired with a double-row suture anchor construct alone or with a suture button and Krackow stitch added to the double-row suture anchor construct. The repairs were then tested to maximum load to failure at 20 mm/min. The mode of failure was recorded, and the mean maximum load to failure was assessed using the Student t test for distributions with equal variance. RESULTS Transcalcaneal drill pin passage did not place any selected anatomic structures at risk. The mean maximum load to failure for the suture bridge group was 239.2 N; it was 391.4 N for the group with the suture button (P = .014). The lateral plantar artery was the structure placed at greatest risk from drill pin placement, with a mean distance of 22.7 mm (range, 16.5-29.2 mm) between the pin and artery. CONCLUSION In this laboratory study, transcalcaneal drill pin passage appeared to be anatomically safe, and the use of suture button technology with a Krackow stitch for Achilles tendon insertional repair significantly increased repair strength. CLINICAL RELEVANCE Achilles tendon insertional repair with suture button fixation and a Krackow stitch may facilitate the earlier institution of postoperative rehabilitation and improve clinical outcomes.
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Affiliation(s)
- Nathan J Fanter
- Hughston Clinic, 6262 Veterans Parkway, PO Box 9517, Columbus, GA 31908-9517, USA
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Nuerai S, Ainuer J, Jiasharete J, Darebai R, Kayrat A, Tang B, Jiangannur Z, Bai J, Makabel B. Kazakh therapy on differential protein expression of Achilles tendon healing in a 7-day postoperative rabbit model. J TRADIT CHIN MED 2012; 31:367-75. [PMID: 22462247 DOI: 10.1016/s0254-6272(12)60020-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To compare the effect of cast immobilization with that of early Kiymil arkili emdew (Kazakh exercise therapy) on the post-operative healing of Achilles tendon rupture in rabbits, and to observe the influence of early Kiymil arkili emdew on the differentially expressed proteins in the healing tendon. METHODS Forty-five New Zealand white rabbits were randomly divided into three groups (Arm A: control group; Arm B: postoperative immobilization group; and Arm C: postoperative early Kiymil arkili emdew group). After tenotomy, the rabbits of the two experimental groups received microsurgery to repair the ruptured tendons, and then received either cast immobilization or early Kiymil arkili emdew treatment. Achilles tendon tissue samples were collected 7 days after the surgery, and two-dimensional gel electrophoresis and MALDI-TOF-MS technique were used to analyze differentially expressed proteins in the tendon tissue of the three Arms. RESULTS A total of 462.67 +/- 11.59, 532.33 +/- 27.79, and 515.33 +/- 6.56 protein spots were detected by the two-dimensional polyacrylamide gels in the Achilles tendon samples of the rabbits in Arms A, B, and C, respectively. Nineteen differentially expressed protein spots were randomly selected from Arm C. Among them, 7 were unique, and 15 had five times higher abundance than those in Arm B. These included annexin A2, gelsolin isoforms and alpha-1 Type III collagen. It was confirmed by western blot that gelsolin isoform b, annexin A2, etc. had specific and incremental expression in Arm C. CONCLUSIONS The self-protective instincts of humans were overlooked in the classical postoperative treatment for Achilles tendon rupture with cast immobilization. Kiymil arkili emdew induced the specific and incremental expression of proteins in the repaired Achilles tendon in the early healing stage in a rabbit model, compared with those treated with postoperative cast immobilization. These differentially expressed proteins may contribute to the healing of the Achilles tendon via a mechanobiological mechanism caused by the application of Kiymil arkili emdew.
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Affiliation(s)
- Shawutali Nuerai
- Department of Microsurgical Repair and Reconstruction, the First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, China
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Abstract
The Achilles tendon is the most injured tendon of athletes in the lower extremities and is the most common tendon to rupture spontaneously. Operative repair provides earlier return to sporting activities and lesser rate of rerupture. The general goal is to attempt anastomosis of the acute ruptured ends; however, delayed ruptures may require more extensive procedures. New surgical approaches, including percutaneous and mini-open techniques, are being introduced to potentially diminish perioperative complications. Advent of early protective range of motion and rehabilitation has shown a potential for earlier return to sporting activities for Achilles ruptures.
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Demirel M, Turhan E, Dereboy F, Yazar T. Augmented repair of acute tendo Achilles ruptures with gastrosoleus turn down flap. Indian J Orthop 2011; 45:45-52. [PMID: 21221223 PMCID: PMC3004079 DOI: 10.4103/0019-5413.73654] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND We present the results of primary repair of acute tendo Achilles (TA) rupture augmented with gastrosoleus turn down flap technique. PATIENTS AND METHODS 78 consecutive patients with a complete acute rupture of the Achilles tendon operated between 1993 and 2004 were included in study. We performed a modification of the Lindholm technique in which the primary Kessler suture repair of the tendon was augmented by a turn-down ~3 cm × 10 cm gastrosoleus aponeurosis flap. In all cases, a short-leg circular walking cast was applied at 90° of the ankle dorsiflexion for 3 weeks and all the patients were encouraged to full weightbearing ambulation immediately. After removal of the cast, isometric and isokinetic ankle exercises were performed for 3 weeks. Modified Rupp Score was used to evaluate the subjective satisfaction. RESULTS All of patients returned to daily activity and 54 (69%) of them returned to previous sport activity. The tendon repair failed in two patients and they were reoperated with an allograft. Three patients developed infection and one of them required débridement. One developed deep venous thrombosis and two permanent sural nerve injuries were encountered. One of the patients had a severe skin necrosis, which was treated with rotation flap. The mean Rupp score was 29 (3-33). CONCLUSION Primary repair of acute tendo Achilles rupture augment with gastrosoleus turn down flip technique in combination of immediate weightbearing ambulation provides a good outcome, but is associated with similar complication rates to the previous literature.
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Affiliation(s)
- Murat Demirel
- Orthopaedic Surgeon, Bayindir Private Hospital, Ankara, Turkey,Address for correspondence: Dr. Murat Demirel, Ankara Bayindir Hospital, Orthopaedics and Traumatology, 1443 cad. Sogutozu Ankara, Turkey. E-mail:
| | - Egemen Turhan
- Department of Orthopaedics, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - Ferit Dereboy
- Orthopaedic Surgeon, Magnet Medical Center, Ankara, Turkey
| | - Tarik Yazar
- Department of Orthopaedics and Traumatology, Dr. Ankara University Faculty of Medicine, Ankara, Turkey
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Factors influencing the tensile strength of repaired Achilles tendon: a biomechanical experiment study. Clin Biomech (Bristol, Avon) 2010; 25:789-95. [PMID: 20696369 DOI: 10.1016/j.clinbiomech.2010.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Revised: 12/17/2009] [Accepted: 05/13/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Operative treatment has been advocated as the method of choice to repair Achilles tendon rupture as surgery results in reduced re-rupture rate and faster rehabilitation. Many surgical techniques have been introduced allowing for postoperative early motion of the ankle joint. However, it is currently very difficult for surgeons to determine the optimal treatment conditions for ruptured Achilles tendon with an increasing number of end-to-end suture methods, suture materials, and epitenon suture techniques. METHODS In the present biomechanical experiment study based on an orthogonal design, thirty-two New Zealand white rabbits received Achilles tendon tenotomy and subsequent operative treatment to repair the tendon employing four end-to-end suture methods, four suture materials, and four epitenon suture techniques. The tensile strength of the repaired Achilles tendon was investigated at four rehabilitation periods, and in comparison with the results of another sixteen rabbits with normal Achilles tendons. FINDINGS The end-to-end suture method contributed most to the final Achilles tendon tensile strength in addition to rehabilitation period, with the highest values occurring with the use of the parachute-like ("Pa" bone) suture method. The other two factors, namely, suture material and epitenon suture technique, had relatively little influence on the results. INTERPRETATION The parachute-like ("Pa" bone) surgical technique is superior to the other three end-to-end suture methods, with enhanced tensile strength of the repaired tendon. This method allows for postoperative early kinesitherapy of the ankle and knee joints. Therefore, this technique is highly recommended in clinical situations for treatment of ruptured Achilles tendon.
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Yotsumoto T, Miyamoto W, Uchio Y. Novel approach to repair of acute achilles tendon rupture: early recovery without postoperative fixation or orthosis. Am J Sports Med 2010; 38:287-92. [PMID: 20044498 DOI: 10.1177/0363546509351557] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Immobilization or orthosis is required after conventional Achilles tendon surgery. Hypothesis This new Achilles tendon repair approach enables early rehabilitation without any postoperative immobilization or orthosis. STUDY DESIGN Case series; Level of evidence, 4. METHODS Twenty consecutive patients (14 men and 6 women; mean age, 43.4 years; range, 16-70 years) who had acute subcutaneous Achilles tendon rupture were treated by the new method, with an average follow-up of 2.9 years (range, 2-4.8 years). Among them, 15 injuries were sports-related and 5 were work-related. The authors applied a side-locking loop technique of their own design for the core suture, using braided polyblend suture thread, with peripheral cross-stitches added. The patients started active and passive ankle mobilization from the next day, partial weightbearing walking from 1 week, full-load walking from 4 weeks, and double-legged heel raises from 6 weeks after surgery. RESULTS The range of motion recovery equal to the intact side averaged 3.2 weeks. Double-legged heel raises and 20 continuous single-legged heel raise exercises were possible at an average of 6.3 weeks and 9.9 weeks, respectively. T2-weighted magnetic resonance signal intensity recovered to equal that of the intact portion of the same tendon at 12 weeks. The patients resumed sports activities or heavy labor at an average of 14.4 weeks. The Achilles tendon rupture score averaged 98.3 at 24 weeks. There were no complications. CONCLUSION This new Achilles tendon repair approach enables early mobilization exercise without costly specialized orthosis or immobilization and allows an early return to normal life and sports activities, reducing the physical and economic burden on patients.
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Affiliation(s)
- Tadahiko Yotsumoto
- Department of Orthopaedic Surgery, Shimane University School of Medicine, 89-1 Enya-cho, Izumo-shi, Shimane-Pref. 693-8501, Japan.
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17
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Abstract
Although the Achilles tendon is the strongest in the body, it also is the most often ruptured. Achilles tendon rupture most often occurs during sports activities in middle-aged men. Operative repair of a ruptured Achilles tendon can be accomplished with a variety of techniques, ranging from open repair, to minimally invasive technique, to endoscopic-assisted repair. This article focuses on open repair of acute Achilles tendon rupture. Surgical techniques, rehabilitation protocol, and the authors' preferred method are described.
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Doral MN, Bozkurt M, Turhan E, Ayvaz M, Atay OA, Uzümcügil A, Leblebicioğlu G, Kaya D, Aydoğ T. Percutaneous suturing of the ruptured Achilles tendon with endoscopic control. Arch Orthop Trauma Surg 2009; 129:1093-101. [PMID: 19404654 DOI: 10.1007/s00402-009-0880-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2008] [Indexed: 10/20/2022]
Abstract
INTRODUCTION A prospective study of modified percutaneous Achilles tendon repair performed between 1999 and 2005 under local infiltration anesthesia is presented; the study evaluated the results of percutaneous repair technique by visualization of the synovia under endoscopic control, followed by early functional postoperative treatment for surgical intervention of acute Achilles tendon ruptures. PATIENTS Sixty-two patients (58 males, 4 females, mean age 32) were treated by percutaneous suturing with modified Bunnel technique under endoscopic control within 10 days after acute total rupture. Physiotherapy was initiated immediately after the operation and patients were encouraged to weight-bearing ambulation with a walking brace-moon boot as tolerated. Full weight-bearing was allowed minimum after 3 weeks postoperatively without brace. RESULTS The procedure was tolerated in all patients. There were no significant ROM limitation was observed. Two patients experienced transient hypoesthesia in the region of sural nerve that spontaneously resolved in 6 months. Fifty-nine patients (95%) including professional athletes returned to their previous sportive activities, while 18 of them (29%) had some minor complaints. The interval from injury to return to regular work and rehabilitation training was 11.7 weeks (10-13 weeks). At the latest follow-up (mean: 46 months; range: 12-78 months), all the patients had satisfactory results with a mean American Orthopedic Foot and Ankle Society's ankle-hindfoot score of 94.6. No re-ruptures, deep venous thrombosis or wound problems occurred. CONCLUSION The proposed method offers a reasonable treatment option for acute total Achilles tendon rupture with a low number of complications. The rerupture rate and return to preinjury activities are comparable to open and percutaneous without endoscopic control procedures.
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Affiliation(s)
- Mahmut Nedim Doral
- Department of Orthopaedics and Sports Medicine, Faculty of Medicine, Hacettepe University, Sihhiye, 06100, Ankara, Turkey.
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Majewski M, Schaeren S, Kohlhaas U, Ochsner PE. Postoperative rehabilitation after percutaneous Achilles tendon repair: Early functional therapy versus cast immobilization. Disabil Rehabil 2009; 30:1726-32. [DOI: 10.1080/09638280701786831] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Fröberg A, Komi P, Ishikawa M, Movin T, Arndt A. Force in the achilles tendon during walking with ankle foot orthosis. Am J Sports Med 2009; 37:1200-7. [PMID: 19229043 DOI: 10.1177/0363546508330126] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ankle foot orthoses are used for postoperative treatment of Achilles tendon ruptures and decrease calf muscle electromyography activity during walking. HYPOTHESIS Achilles tendon load decreases with increased restriction of dorsiflexion and is associated with decreased triceps surae activity. STUDY DESIGN Controlled laboratory study. METHODS In 8 subjects, the maximum force and rate of force development in the Achilles tendon were measured with an optic fiber technique, and the activity of the gastrocnemius, soleus, and tibialis anterior muscles was recorded using electromyography. Trial conditions were walking barefoot and wearing an ankle-foot orthoses set in 3 different positions: (1) locked at 20 degrees of plantar flexion and with free plantar flexion but restricted dorsiflexion to (2) 10 degrees plantar flexion and (3) 10 degrees dorsiflexion, respectively. The design of the ankle foot orthoses did not provide heel support when fixed in a plantarflexed position. RESULTS Maximum Achilles tendon force was highest at the ankle-foot orthoses setting of 20 degrees plantar flexion (3.1 times body weight) and decreased to 2.1 times body weight during barefoot walking (P < .01). The rate of Achilles tendon force showed an increasing trend with less-restricted dorsiflexion. Soleus activity was 52% of mean barefoot walking activity at 3 20 degrees plantar flexion (P < .001) and then increased as dorsiflexion was less restricted. CONCLUSION Weightbearing in ankle-foot orthoses when dorsiflexion is restricted beyond neutral may result in increased forces in the Achilles tendon compared with barefoot walking, despite reduced electromyography activity in the triceps surae and decreased rate of force development. CLINICAL RELEVANCE If patients bear full weight in an ankle-foot orthoses locked at 20 degrees plantar flexion without heel support, the maximum force in the tendon may exceed that encountered during barefoot walking.
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Affiliation(s)
- Asa Fröberg
- Karolinska Institute, Department of Clinical Science, Intervention and Technology, Division of Orthopedic Surgery, Stockholm 14186, Sweden.
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Pajala A, Kangas J, Siira P, Ohtonen P, Leppilahti J. Augmented compared with nonaugmented surgical repair of a fresh total Achilles tendon rupture. A prospective randomized study. J Bone Joint Surg Am 2009; 91:1092-100. [PMID: 19411457 DOI: 10.2106/jbjs.g.01089] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Augmented and nonaugmented techniques have been used for the operative repair of a fresh complete Achilles tendon rupture. Augmented techniques have been favored for their stronger pullout strengths but have been avoided because of the risk of wound complications. If proven to be equally good, the nonaugmented technique would be the method of choice. In the present study, we hypothesized that augmentation with a down-turned gastrocnemius fascia flap would not provide better results than would end-to-end suture repair with use of the Krackow locking loop surgical technique. METHODS Sixty patients with an acute Achilles tendon rupture were randomized preoperatively to receive end-to-end suture repair with use of the Krackow locking loop technique either without augmentation (simple repair group) or with a down-turned gastrocnemius fascia flap as described by Silfverskiöld (augmented repair group). A brace allowed free active plantar flexion of the ankle postoperatively, whereas dorsiflexion was restricted to neutral for the first three weeks. Weight-bearing was limited for six weeks. The follow-up period was one year, and the patients were evaluated in terms of clinical measurements, an outcome score, isokinetic calf muscle performance tests, and tendon elongation measurements. RESULTS The mean operative time was twenty-five minutes longer and the incision was 7 cm longer in the augmented repair group as compared with the simple repair group (p < 0.001 for both). In the simple repair group, the overall ankle score was excellent for nineteen patients (63%) and good for eight patients (27%) and three patients (10%) had an early failure (all because of rerupture). In the augmented repair group, the ankle score was excellent for fourteen patients (56%) and good for six patients (24%) and five patients (20%) had a failure because of rerupture (three) or deep infection (two). The difference between the groups with regard to the overall result was not significant (p = 0.68). In the simple repair group the isokinetic calf muscle strength score was excellent for eleven patients (37%), good for fourteen patients (47%), and fair for two patients (7%), with three patients (10%) having a failure, whereas in the augmented repair group the score was excellent for nine patients (36%), good for seven patients (28%), fair for three patients (12%), and poor for one patient (4%), with five patients (20%) having an early failure. Achilles tendon elongation occurred in both groups, and elongation correlated significantly with isokinetic peak torque deficits (rho = 0.64, p = 0.001) and isometric strength deficits (rho = 0.48, p = 0.026) in the simple repair group. No significant differences were seen between the two groups at the three-month and twelve-month checkups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, overall outcome, isokinetic calf muscle strength, mean peak work-displacement relationships, or tendon elongation. CONCLUSIONS Augmented repair of a fresh total Achilles tendon rupture does not have any advantage over simple end-to-end repair.
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Affiliation(s)
- Ari Pajala
- Department of Surgery, Division of Trauma Surgery, Oulu University Hospital, Oulu, Finland.
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Nishimura K, Mori R, Miyamoto W, Uchio Y. A new technique for small and secure knots using slippery polyethylene sutures. Clin Biomech (Bristol, Avon) 2009; 24:403-6. [PMID: 19261363 DOI: 10.1016/j.clinbiomech.2009.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 01/25/2009] [Accepted: 01/30/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Suture knots used in tendon surgery must be strong but small enough so that they do not hinder gliding. For this purpose, we devised a unique "antislip" knot. METHODS Three suture materials were used: Ethibond, Fiberwire, and Nespron. They were tied with either the antislip knot using a pair of United States Pharmacopeia (USP) 2 sutures or with a conventional reef knot using USP2 single sutures. The volume and tensile strength of the knots were measured (n = 25 for each combination of suture and method). FINDINGS The maximum tensile strength was observed with Fiberwire antislip knots with five throws (mean 587 N) and six throws (mean 590 N), and Nespron antislip knots with five throws (mean 554 N) and six throws (mean 552 N); no significant differences were found among the four knots. Tensile strength per volume showed maximum values with Fiberwire antislip knots with four throws (mean 17.4 N/microl) and five throws (mean 16.8 N/microl), and Nespron antislip knots with four throws (mean 17.6 N/microl) and five throws (mean 16.8N/microl), which were not significantly different and were over 1.25-fold greater than the value for a reef knot. Ethibond had less tensile strength than Fiberwire and Nespron. INTERPRETATION The antislip knot is smaller for the same or greater strength than a conventional reef knot. The 4- or 5-throw antislip knot was most effective for slippery polyethylene sutures such as Fiberwire and Nespron. The antislip knot should improve biological healing of repaired tendons through accelerated rehabilitation.
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Affiliation(s)
- Kazushi Nishimura
- Department of Orthopaedic Surgery, Shimane University School of Medicine, 89-1 Enya, Izumo, Shimane 693-8501, Japan
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Lee SJ, Sileo MJ, Kremenic IJ, Orishimo K, Ben-Avi S, Nicholas SJ, McHugh M. Cyclic loading of 3 Achilles tendon repairs simulating early postoperative forces. Am J Sports Med 2009; 37:786-90. [PMID: 19204367 DOI: 10.1177/0363546508328595] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The abstract goes here and covers two columns. Accelerated rehabilitation has been advocated after Achilles tendon repair, but it produces significant forces at the repair site. The abstract goes here and covers two columns. HYPOTHESIS Stresses applied to the repaired Achilles tendon simulating postoperative forces may exceed the strength of some repairs. STUDY DESIGN Controlled laboratory study. METHODS Fifteen Achilles tendons were incised 4 cm proximal to the calcaneal insertion, then were repaired using either a percutaneous, 4-strand Krackow, or an epitendinous augmented 4-strand Krackow technique. Tendons were cyclically loaded to 1000 cycles each at 100, 190, and 369 N. The number of cycles to initial gapping, 5-mm gapping, and total failure were compared using Mann-Whitney U tests with adjustments for multiple comparisons. RESULTS Gap resistance was significantly greater for augmented Krackow repairs (2208 cycles to initial gapping) versus nonaugmented repairs (502 cycles, P = .024) and for nonaugmented Krackow repairs versus percutaneous repairs (5 cycles, P = .024). All percutaneous repairs failed during the 100-N cycling (102 +/- 135 cycles). All nonaugmented Krackow repairs failed during the 190-N cycles (total cycles to failure: 1268 +/- 345). All augmented Krackow repairs were intact (no gapping) after the 190-N cycles. Four failed during 369-N cycling (total cycles to failure, 2017 +/- 11), and 1 remained intact for 3000 cycles. CONCLUSION Epitendinous cross-stitch weave augmentation of Achilles tendon repairs significantly increased repair strength and gap resistance. CLINICAL RELEVANCE Epitendinous cross-stitch weave augmentation of Achilles tendon repairs may better allow for early stretching and ambulation after Achilles tendon repair.
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Affiliation(s)
- Steven J Lee
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
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Lee SJ, Goldsmith S, Nicholas SJ, McHugh M, Kremenic I, Ben-Avi S. Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of achilles tendon repairs. Foot Ankle Int 2008; 29:427-32. [PMID: 18442459 DOI: 10.3113/fai.2008.0427] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Epitendinous suture augmentation has been shown to increase gap resistance and overall strength in flexor tendon repairs of the hand. The purpose of this study was to evaluate the effect of various suture augmentation techniques in Achilles tendon repair. MATERIALS AND METHODS Eighteen fresh-frozen cadaveric Achilles tendons were transected and repaired with a 4-strand Krackow core stitch. Suture augmentation was performed with 3 figure-of-eight stitches in 6 specimens and a running cross-stitch weave in 6 specimens. The other 6 specimens were not augmented. Each tendon was loaded to failure on an MTS. Force to failure (defined as peak force or force at 5 mm gapping), gapping resistance, stiffness, and elongation were compared. RESULTS Force to failure (p < 0.001), stiffness (p < 0.01) and gapping resistance (p < 0.05) were increased by suture augmentation. Additionally failure force and gapping resistance for the cross-stitch augmentation was higher than the figure-of-eight augmentation (p < 0.05). CONCLUSION Cross-stitch augmentation of Achilles tendon repair yields a stronger and stiffer repair with greater resistance to gapping. CLINICAL RELEVANCE Achilles tendon repairs augmented with a cross stitch weave will be able to withstand substantially higher forces than non-augmented repairs.
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Affiliation(s)
- Steven J Lee
- Lenox Hill Hospital, Orthopedic Surgery, 130 East 77th Street, 5th Floor, Black Hall, New York, NY 10021.
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Pihlajamäki H, Tynninen O, Karjalainen P, Rokkanen P. Enveloping bioabsorbable polyglycolide membrane and immobilization in Achilles tendon repair: A comparative experimental study on rabbits. J Orthop Res 2008; 26:264-70. [PMID: 17902177 DOI: 10.1002/jor.20504] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Using qualitative and histoquantitative methods, we investigated the effect of immobilization versus nonimmobilization on the biodegradation process, implant-tissue interaction, and scar formation after enveloping a rejoined rabbit Achilles tendon with a self-reinforced polyglycolide (SR-PGA) membrane. The soleus and gastrocnemius tendons of the right hind legs of 40 rabbits were transected. After suturing the ends, the seam was enveloped with the bioabsorbable membrane. Twenty ankles were immobilized with cast, 20 remained nonimmobilized. All nonoperated left ankles served as intact controls. During the follow-up of 3, 6, 12, and 24 weeks, scar formation, tissue response, and membrane biodegradation were studied histologically and histomorphometrically. The amount of scar tissue, highest at 3 weeks, gradually approached intact controls. SR-PGA degradation in both cast and noncast specimens was near complete by 24 weeks. Signs of an inflammatory process were most prominent at 3 weeks and diminished gradually by 24 weeks. No significant difference between cast and noncast specimens was noted at any time point regarding the amount of scar tissue, degradation process of PGA, or intensity of inflammatory reaction. In the present experimental setting, cast immobilization influenced neither scar formation nor speed of degradation during reunion of transected Achilles tendon ends as compared with nonimmobilization. No differences in the reunion process of the tendon ends were seen between the immobilized and nonimmobilized groups. Moreover, inflammatory cells were similar in both groups and reflected a transient tissue reaction to the membrane. Within the follow-up, the seam area (cross-sectional) approached that of intact controls.
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Affiliation(s)
- Harri Pihlajamäki
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, P.O. Box 266, 00029 HUS, Helsinki, Finland.
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Lee DK. A preliminary study on the effects of acellular tissue graft augmentation in acute Achilles tendon ruptures. J Foot Ankle Surg 2007; 47:8-12. [PMID: 18156058 DOI: 10.1053/j.jfas.2007.08.015] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Indexed: 02/03/2023]
Abstract
Acute Achilles tendon rupture injuries present surgical challenges because of the mechanical forces placed on this tendon. The purpose of this study was to evaluate the effectiveness of an acellular human dermal tissue matrix, GraftJacket Matrix (Wright Medical Technology, Inc., Arlington, TN), as an augmentation material in acute Achilles tendon repair. Eleven consecutive patients with acute tendon ruptures were evaluated and followed up (20-31 months). Primary repair was followed by augmentation with the graft sutured circumferentially around the tendon. Patients were placed in an early functional rehabilitation program with postoperative evaluation at 3, 6, and 12 months. Outcome scores were calculated based on the American Orthopaedic Foot and Ankle Society ankle-hindfoot scoring system. At 20-month postoperative follow-up, there have been no cases of rerupture or recurrent pain. The average return-to-activity time was 11.8 +/- 0.75 weeks. These retrospective clinical results suggest that with an acellular human dermal tissue matrix to augment acute Achilles tendon, primary repair offers a desirable return-to-activity time without any rerupture or complications. ACFAS Level of Clinical Evidence: 2c.
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Affiliation(s)
- Daniel K Lee
- Department of Orthopaedic Surgery, University of California, San Diego, 350 Dickinson St, MC 8894, San Diego, CA 92103, USA.
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Abstract
BACKGROUND Treatment of Achilles tendon rupture has long been at the center of debate. HYPOTHESIS A new technique in surgical Achilles tendon repair allows for more stability and earlier rehabilitation. STUDY DESIGN Case series; Level of evidence, 4. METHODS One hundred Achilles tendon rupture patients (70 men, 30 women; age range, 16-54 years; mean age, 32 years) were treated by a newly modified method of repair. Twenty-one of these patients were high-level athletes, and 79 were recreational-level athletes. The average length of follow-up was 2.4 years (range, 1-6.3 years), and none of the ruptures included avulsion fractures. After adjusting the tendon to an adequate length using a Tsuge suture, each fibrous bundle was gathered in a longitudinal direction and fixed with a Bunnell-type suture. The same postoperative physical therapy protocol was applied to all patients: at 1 week, early full weightbearing with a walking cast was initiated, and at 2 weeks, patients began range of motion (ROM) exercises and were instructed to wear a hinged ankle-foot orthosis that permitted full plantar flexion but limited full dorsiflexion. From 6 weeks, patients started practicing double-legged heel raises. RESULTS At an average of 10 weeks, ankle ROM was comparable to that of the nonoperated leg, and double-legged heel raises were achieved at an average of 7.6 weeks. On average, patients were able to do 20 continuous single-legged heel-raising motions (equivalent to manual muscle testing grade 5) at 15.4 weeks, and jogging started at 12.3 weeks. High-level athletes returned to their original sports level at an average of 5 months. Two reruptures (2%) were experienced, but no other complications occurred. CONCLUSION This surgical technique allows for strong repair stability and subsequent early weightbearing and ROM exercises.
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Shepard ME, Lindsey DP, Chou LB. Biomechanical testing of epitenon suture strength in Achilles tendon repairs. Foot Ankle Int 2007; 28:1074-7. [PMID: 17923058 DOI: 10.3113/fai.2007.1074] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent evidence that early, active mobilization protocols after Achilles tendon repairs increase recovery speed and strength make operative repair strength critical to positive outcomes after Achilles tendon ruptures. While previous research has focused on core (tendon proper) repair techniques, no previous literature has reported testing of core repairs augmented with epitenon sutures, which have been shown to increase the strength of repairs of flexor tendons of the hand. METHODS Five matched pairs of fresh frozen human Achilles tendons were tested with and without the addition of an epitenon suture to the core repair suture. All specimens were repaired using a No. 2 Ethibond Krakow locking loop core suture. The epitenon suture was added to one tendon randomly chosen from each pair, using a 4-0 nylon suture. All specimens were mounted on an MTS testing machine (MTS Systems Corp., Eden Prairie, MN) and loaded to failure, which was defined as a 1-cm gap formation. RESULTS The addition of epitenon sutures significantly increased the force necessary to produce a 2-mm gap as compared to core sutures alone by 74%, and it increased the average load to failure by 119%. Also, initial tendon stiffness was 173% greater in tendons reinforced with epitenon sutures. CONCLUSIONS This study demonstrates that greater resistance to gap formation, approximation of tissue ends, and tensile strength were achieved by the addition of an epitenon suture. Clinical relevance may improve healing by decreased gap formation at the repair site and a lower risk of adhesion formation.
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Ji JH, Kim WY, Kim YY, Lee YS, Yoon JS. Semitendinosus tendon augmentation for a large defect after Achilles tendon rupture: two case reports. Foot Ankle Int 2007; 28:1100-3. [PMID: 17923064 DOI: 10.3113/fai.2007.1100] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jong Hun Ji
- Department of Orthopaedic Surgery, Daejeon St Mary's Hospital, 520-2, Daehung-Dong, Jung-Gu, Daejeon, Korea.
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Jacob KM, Paterson R. SURGICAL REPAIR FOLLOWED BY FUNCTIONAL REHABILITATION FOR ACUTE AND CHRONIC ACHILLES TENDON INJURIES: EXCELLENT FUNCTIONAL RESULTS, PATIENT SATISFACTION AND NO RERUPTURES. ANZ J Surg 2007; 77:287-91. [PMID: 17388838 DOI: 10.1111/j.1445-2197.2007.04035.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND We evaluated 46 patients who underwent surgical repair of the Achilles tendon at our institution during a 4.5-year period, followed by early weight bearing, aiming to assess their return to activities, rerupture rate and satisfaction. METHODS A cohort of 46 patients who underwent Achilles tendon repair at our institution during a 4.5-year period, with a modified triple mini-Becker suture technique, for both acute as well as chronic Achilles tendon ruptures were studied. These patients were reviewed at a minimum of 2.5 years follow up (average 4.5 years ranging from 2.5 to 6.5 years), by chart review and questionnaire, to determine the functional outcome as well as patient satisfaction following an active postoperative protocol involving full weight-bearing ambulation in a controlled ankle motion walker and active stretching, followed by a graduated strengthening programme. RESULTS We found a very high level of satisfaction, with few minor complications and no reruptures in either the early or the delayed repair groups. CONCLUSION We believe that surgical repair using this technique associated with an early return to protected full weight-bearing ambulation and an active early rehabilitation programme provides not only excellent functional results, patient satisfaction and a zero rerupture rate, but also much less morbidity in the first 3 months and a quicker overall recovery compared with non-operative treatment.
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Benthien RA, Aronow MS, Doran-Diaz V, Sullivan RJ, Naujoks R, Adams DJ. Cyclic loading of Achilles tendon repairs: a comparison of polyester and polyblend suture. Foot Ankle Int 2006; 27:512-8. [PMID: 16842718 DOI: 10.1177/107110070602700706] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Early functional rehabilitation is widely used after open suture repair of the Achilles tendon. To our knowledge, no previous studies have assessed gap formation from cyclic loading and subsequent failure loads of simulated Achilles tendon repairs. A synthetic (polyblend) suture has been introduced for tendon repairs with reportedly greater strength than polyester suture. This stronger, stiffer suture material may provide stronger repairs with less elongation of the tendon repair. METHODS Simulated Achilles tendon ruptures in bovine Achilles tendon were repaired with a four-strand Krackow suture technique using No. 2 polyester suture. Specimens were loaded for 3,000 cycles at maximal loads of 50, 75, 100, or 125 N, and gap formation at the repair site was continuously measured. After cyclic loading, each specimen was loaded to failure. Identical repairs were performed with number 2 polyblend suture and cyclically loaded to 75 N for 3,000 cycles. All specimens were loaded to failure. RESULTS Cyclically loading polyester suture repairs to 50, 75, 100, or 125 N for 3,000 cycles resulted in mean gapping at the repair site of 3.0 +/- 0.8, 4.9 +/- 1.0, 7.2 +/- 0.9, and 7.9 +/- 0.8 mm, respectively. Cyclically loading the polyblend suture repairs for 3,000 cycles at 75 N, resulted in 3.3 +/- 0.3 mm of gap formation at the repair site, significantly less than polyester suture repairs (p < 0.001). The mean load to failure for polyester suture repair was 222 +/- 19 N and for polyblend suture repair was 582 +/- 49 N, a statistically significant difference (p < 0.001). Gap formation at 100, 1,000, and 2,000 cycles, as a percentage of total gap formation at 3,000 cycles, was 64.3%, 87.5%, and 95.4% for polyester suture and 45.8%, 78.5%, and 90.1% for polyblend repairs. All specimens in all groups failed at the knots during load-to-failure testing. CONCLUSIONS Cyclic loading of simulated Achilles tendon repairs using a Krackow, four-core polyester suture technique showed progressive gap formation with increasing load. All repairs failed at the knot, and suture pull-out from tendon was not observed. Polyblend suture repair, when compared to identical repairs with braided polyester suture, resulted in a 260% higher load to failure and 33% less gap formation at the repair site after 3,000 cycles. CLINICAL RELEVANCE The use of polyblend suture in a four-stranded Krackow configuration provides stronger repairs with less gap formation, which may provide increased security during early functional rehabilitation.
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Affiliation(s)
- Ross A Benthien
- Orthopedic Associates of Hartford, 85 Seymour Street, Suite 607, Hartford, CT 06106, USA.
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Mullaney MJ, McHugh MP, Tyler TF, Nicholas SJ, Lee SJ. Weakness in end-range plantar flexion after Achilles tendon repair. Am J Sports Med 2006; 34:1120-5. [PMID: 16476917 DOI: 10.1177/0363546505284186] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Separation of tendon ends after Achilles tendon repair may affect the tendon repair process and lead to postoperative end-range plantarflexion weakness. HYPOTHESIS Patients will have disproportionate end-range plantarflexion weakness after Achilles tendon repair. STUDY DESIGN Descriptive laboratory study. METHODS Four-strand core suture repairs of Achilles tendon were performed on 1 female and 19 male patients. Postoperatively, patients were nonweightbearing with the ankle immobilized for 4 weeks. Plantarflexion torque, dorsiflexion range of motion, passive joint stiffness, toe walking, and standing single-legged heel rise (on an incline, decline, and level surface) were assessed after surgery (mean, 1.8 years postoperative; range, 6 months-9 years). Maximum isometric plantarflexion torque was measured at 20 degrees and 10 degrees of dorsiflexion, neutral, and 10 degrees and 20 degrees of plantar flexion. Percentage strength deficit (relative to noninvolved leg) was computed at each angle. Passive dorsiflexion range of motion was measured goniometrically. Passive joint stiffness was computed from increase in passive torque between 10 degrees and 20 degrees of dorsiflexion, before isometric contractions. RESULTS Significant plantarflexion weakness was evident on the involved side at 20 degrees and 10 degrees of plantar flexion (34% and 20% deficits, respectively; P <.001), with no torque deficits evident at other angles (6% at neutral, 3% at 10 degrees of dorsiflexion, 0% at 20 degrees of dorsiflexion). Dorsiflexion range of motion was not different between involved and noninvolved sides (P = .7). Passive joint stiffness was 34% lower on the involved side (P <.01). All patients could perform an incline heel rise; 14 patients could not perform a decline heel rise (P <.01). CONCLUSION Disproportionate weakness in end-range plantar flexion, decreased passive stiffness in dorsiflexion, and inability to perform a decline heel rise are evident after Achilles tendon repair. Possible causes include anatomical lengthening, increased tendon compliance, and insufficient rehabilitation after Achilles tendon repair. CLINICAL RELEVANCE Impairments will have functional implications for activities (eg, descending stairs and landing from a jump). Weakness in end-range plantar flexion may be an unrecognized problem after Achilles tendon repair.
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Affiliation(s)
- Michael J Mullaney
- Nicholas Institute of Sports Medicine & Athletic Trauma, Lenox Hill Hospital, New York, NY 10021, USA.
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Abstract
BACKGROUND Surgical and nonsurgical treatments of Achilles tendon ruptures are available. Nonsurgical treatment using immobilization does not have the varying degrees of infection as seen with surgical procedures, but it frequently is linked to muscle atrophy, weakness, and higher rates of rerupture than surgical treatment. This study reports the results of 64 patients with Achilles tendon ruptures treated surgically and with early mobilization. METHODS Surgery of the ruptured tendon involved dividing the proximal stump into two separate strands and the distal stump into a single strand. The repair was advanced to a V-Y formation, and nonabsorbable sutures were used for repair. After wound closure, an early mobilization rehabilitation program was initiated, which consisted of wearing a moveable ankle brace for 4 to 6 weeks in 0 to 15 degrees of dorsiflexion and 10 weeks of regular exercises. RESULTS All 64 patients resumed normal activities in an average of 3.3 months regardless of whether the rupture was acute or chronic. Tendons healed with no reruptures. There were 13 complications, all wound infections, which healed when treated with antibiotics. The infection rate dropped markedly when wounds were inspected and dressings changed 1 week postoperatively, instead of at 2 weeks. CONCLUSION Surgery combined with early mobilization reduces range of motion loss, increases blood supply, and reduces the degree of muscle atrophy that typically occurs after Achilles tendon rupture, thereby decreasing the time to resumption of normal activities. Applying tension to the tendon also improved strength of the calf muscles and improved ankle movement. The main concern with early mobilization is rerupture, but this was lessened by patients carefully following the weightbearing and early mobilization protocols. The results of this study strengthen the argument to employ early mobilization rehabilitation after surgical repair.
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Affiliation(s)
- Samiul J Sorrenti
- North Sydney Orthopaedic And Sports Medicine Centre, Sydney, NSW, Australia.
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Yildirim Y, Kara H, Cabukoglu C, Esemenli T. Suture holding capacity of the Achilles tendon during the healing period: an in vivo experimental study in rabbits. Foot Ankle Int 2006; 27:121-4. [PMID: 16487465 DOI: 10.1177/107110070602700209] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Early motion and weightbearing is known to promote the healing of Achilles tendon repair. It is important to be informed about the repair strength for a secure rehabilitation. There are reports about the initial repair strength of Achilles tendons; however, they are mainly in vitro studies that represent the time zero strength of the repair. Softening of the tendon observed during the biological process of the tendon healing, which may effect the suture holding capacity and in turn the repair strength of the tendon has not been evaluated before. METHODS In the current study, the suture holding capacity of rabbit Achilles tendon was observed at various times during the healing period. RESULTS The suture holding capacity of the tendon at the end of the first and third weeks after surgery was found to be similar within 30% of the control tendon. However, at the end of the fourth week it was doubled reaching 65% of the control tendon. CONCLUSIONS Intrinsic tendon insufficiency which causes a decrease in the suture holding capacity of the tendon may lead to pull-out of the suture material during the postoperative third week. This period is precarious for early motion and weightbearing since the suture holding capacity of the tendon doubled relative to the previous three weeks.
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Affiliation(s)
- Yakup Yildirim
- Acibadem Hospital, Department of Orthopaedic Surgery, Bagdat Caddesi Plk. Bagdat Cad, 347/7-8 Erenkoy 81070, Istanbul, Turkey
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Jenson PW, Lillich JD, Roush JK, Gaughan EM. Ex Vivo Strength Comparison of Bioabsorbable Tendon Plates and Bioabsorbable Suture in a 3-Loop Pulley Pattern for Repair of Transected Flexor Tendons from Horse Cadavers. Vet Surg 2005; 34:565-70. [PMID: 16343143 DOI: 10.1111/j.1532-950x.2005.00089.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test the failure strength and energy of 2 bioabsorbable implants applied to transected deep digital flexor tendons (DDFT) from adult horses. STUDY DESIGN Ex vivo biomechanical experiment. SAMPLE POPULATION Twelve pairs of deep digital flexor tendons harvested from the forelimbs of fresh equine cadavers. METHODS Poly-L-lactic acid tendon plates were custom manufactured for application to the cylindrical surface of an adult equine deep digital flexor tendon. Twelve pairs of DDFTs were transected 2 cm distal to the insertion of the distal check ligament of the deep digital flexor tendon. One tendon of each pair was randomly selected for repair with a biodegradable plate or a 3-loop pulley method. Size 2 polydioxanone suture was used in both repairs. Repairs were tested in tension to failure, with peak force (PF) and total energy (TE) at repair failure recorded in Newtons (N) and Joules (J), respectively. A paired t-test was used for statistical evaluation with a significant level set at P< or = .05. RESULTS Mean+/-SD PF for failure of plated tendons (1507.08+/-184.34 N) was significantly greater than for sutured tendons (460.86+/-60.93 N). TE was also significantly greater for failure of plated tendons versus sutured tendons. CONCLUSIONS Plate fixation of transected cadaver DDFTs appear to have superior immediate failure strength than 3-loop pulley repairs. CLINICAL RELEVANCE Whereas in vivo testing is required, a bioabsorbable tendon plate may provide initial increased strength to support tendon healing and decrease external coaptation requirements.
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Affiliation(s)
- Paul W Jenson
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66506, USA.
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Yotsumoto T, Mori R, Uchio Y. Optimum locations of the locking loop and knot in tendon sutures based on the locking Kessler method. J Orthop Sci 2005; 10:515-20. [PMID: 16193365 DOI: 10.1007/s00776-005-0929-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2004] [Accepted: 06/16/2005] [Indexed: 02/09/2023]
Abstract
BACKGROUND We investigated the factors that influence tensile strength and resistance to gap formation at the repair site of tendon suture (stiffness) by comparing (1) the location of the locking loops and (2) the location of the knot. METHODS Transected bovine tendons of the medial gastrocnemius (9-11 x 14-16 mm diameter) were sutured with a modified locking Kessler method with a USP (United States Pharmacopeial convention) 2 polyester multifilament suture (0.500-0.599 mm) and loaded to failure using an Instron 5565 tensiometer. The locking loops were located on either the upper surface facing the operator or on side portions of the tendon. The knot was positioned either close to or far from the tendon stump. RESULTS The locations of the locking loops did not influence the tensile strength; however, the stiffness of the side loop suture (5.70 +/- 0.09 N/mm) was significantly higher than that of the upper surface loop suture (5.17 +/- 0.10 N/mm). Regarding the knot location, the tensile strength with the knot far from the tendon stump (195.1 +/- 4.8 N) was significantly higher than that with the knot close to the tendon stump (169.0 +/- 3.6 N), although the stiffness was unchanged by differences in knot location. CONCLUSIONS These data suggested that a greater tensile strength with less of a gap is obtained by (1) forming locking loops in the side portion of the tendon, and (2) forming knots far from the tendon stump.
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Affiliation(s)
- Tadahiko Yotsumoto
- Department of Orthopaedics, Shimane University School of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan
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Abstract
Achilles tendon ruptures are common, and their incidence is increasing. The evidence for best management is controversial, and, in selected patients, conservative management and early mobilization achieves excellent results. Surgery is associated with an increased risk of superficial skin breakdown; however, modern techniques of percutaneous repair that are performed under local anesthesia and followed by early functional rehabilitation are becoming increasingly common, and should be considered when managing such patients.
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Affiliation(s)
- Tomas Movin
- Department of Orthopaedics, Huddinge Hospital, Karolinska Institute, S-14186 Stockholm, Sweden
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Aoki M, Miyamoto S, Okamura K, Yamashita T, Ikada Y, Matsuda S. Tensile properties and biological response of poly(L-lactic acid) felt graft: an experimental trial for rotator-cuff reconstruction. J Biomed Mater Res B Appl Biomater 2005; 71:252-9. [PMID: 15455368 DOI: 10.1002/jbm.b.30084] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Poly(L-lactic acid) felt (PLLA felt) was prepared for reconstruction of the rotator cuff in animal models. Small changes were found in the tensile strength of both the cultured PLLA felt and the PLLA felt implanted on the paravertebral muscle of rabbits up to 16 postoperative weeks. The stiffness of the felt implanted on the muscle from 6 to 16 weeks showed a statistically significant increase. When the infraspinatus tendons of beagle dog were reconstructed with the PLLA felt, the ultimate strength of PLLA felt increased threefold, and the stiffness increased fivefold by 16 postoperative weeks compared to that of the initial PLLA felt. They were statistically significant (p < 0.01). All the implanted specimens ruptured at the junction between the bone and the PLLA felt. Histological examination demonstrated infiltration of fibrous tissue into the interstices of the PLLA felt fibers. Connection between the infraspinatus tendon and the PLLA felt was tight with the formed scar tissue, but the connective tissue between the bone and PLLA felt fibers was sparse even at 16 and 32 postoperative weeks. A few deteriorated PLLA felt fibers were observed at 32 postoperative weeks. It was concluded that the degradation rate of PLLA felt was low and the tensile recovery of the PLLA felt graft in beagle dogs was excellent. Thus, PLLA felt might be a useful bioabsorbable material for rotator-cuff reconstruction.
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Affiliation(s)
- Mitsuhiro Aoki
- Department of Physical Therapy, Sapporo Medical University School of Health Sciences, Chuo-ku, Japan.
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Abstract
Despite various attempts to repair and replace injured tendon, an understanding of the repair processes and a systematic approach to achieving functional efficacy remain elusive. In this review the epidemiology of tendon injury and repair is first examined. Using a traditional paradigm for repair assessment, the biology and biomechanics of normal tendon, natural healing, and repair are then explored. New treatment strategies such as functional tissue engineering are discussed, including a functional approach to treatment that involves the development of in vivo functional design parameters to judge the acceptability of a repair outcome. The paper concludes with future directions.
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Affiliation(s)
- David L Butler
- Department of Biomedical Engineering, Noyes-Giannestras Biomechanics Laboratory, University of Cincinnati, Cincinnati, Ohio 45221-0048, USA.
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Traumatic Achilles Tendon Rupture in a Female College Basketball Player. J Sport Rehabil 2004. [DOI: 10.1123/jsr.13.2.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective:To present the case of a Division I female college basketball player with a complete Achilles tendon rupture.Background:A 19-year-old, female college basketball player ruptured her right Achilles tendon during preseason conditioning. She had no previous history of heel cord symptoms.Treatment:The athlete underwent open surgical repair of Achilles tendon. The athlete successfully progressed through a functional rehabilitation program focused on early mobilization and weight bearing. The rehabilitation program was continually modified to address deficiencies and to keep the athlete actively engaged. She was cleared for full, unrestricted activity 15 weeks and 3 days after surgery and returned to game participation in 16 weeks.Conclusions:This case provides evidence that early mobilization and weight bearing can be used while still protecting the repaired tendon.
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Sizer PS, Phelps V, Dedrick G, James R, Matthijs O. Diagnosis and Management of the Painful Ankle/Foot. Part 2: Examination, Interpretation, and Management. Pain Pract 2003; 3:343-74. [PMID: 17166130 DOI: 10.1111/j.1530-7085.2003.03038.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Diagnosis, interpretation, and subsequent management of ankle/foot pathology can be challenging to clinicians. A sensitive and specific physical examination is the strategy of choice for diagnosing selected ankle/foot injuries and additional diagnostic procedures, at considerable cost, may not provide additional information for clinical diagnosis and management. Because of a distal location in the sclerotome and the reduced convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns are low and the localization of symptoms is trustworthy. Effective management of the painful ankle/foot is closely linked to a tissue-specific clinical examination. The examination of the ankle/foot should include passive and resistive tests that provide information regarding movement limitations and pain provocation. Special tests can augment the findings from the examination, suggesting compromises in the structural and functional integrity of the ankle/foot complex. The weight bearing function of the ankle/foot compounds the clinician's diagnostic picture, as limits and pain provocation are frequently produced only when the patient attempts to function in weight bearing. As a consequence, clinicians should consider this feature by implementing numerous weightbearing components in the diagnosis and management of ankle/foot afflictions. Limits in passive motion can be classified as either capsular or non-capsular patterns. Conversely, patients can present with ankle/foot pain that demonstrates no limitation of motion. Bursitis, tendopathy, compression neuropathy, and instability can produce ankle/foot pain that is challenging to diagnose, especially when they are the consequence of functional weight bearing. Numerous non-surgical measures can be implemented in treating the painful ankle/foot, reserving surgical interventions for those patients who are resistant to conservative care.
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Affiliation(s)
- Phillip S Sizer
- Texas Tech University Health Science Center, School of Allied Health, Doctorate of Science Program in Physical Therapy, Lubbock, Texas 79430, USA
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Lewis N, Quitkin HM. Strength analysis and comparison of the Teno Fix Tendon Repair System with the two-strand modified Kessler repair in the Achilles tendon. Foot Ankle Int 2003; 24:857-60. [PMID: 14655891 DOI: 10.1177/107110070302401109] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Various options exist for repair of Achilles tendon ruptures, yet a method that consistently provides sufficient gap resistance to allow early mobilization remains elusive. This study compares the mechanical performance of a modified Kessler repair with that of the Teno Fix Tendon Repair System (Ortheon Medical, LLC) in matched pairs of cadaver Achilles tendons. METHODS The two-strand modified Kessler repair was selected as the control construct on the basis of literature review and physician interviews which identified it among the many options as a popular method for repair of acutely ruptured Achilles tendons. Test specimens were harvested from matched pairs of cadaver ankles. The tendons were transected 3.5 cm proximal to the calcaneal insertion and repaired with either the two-strand modified Kessler suture construct or the Teno Fix Tendon Repair System. Assignment to the modified Kessler or Teno Fix group was done randomly for the first member of each pair. All test and control repairs were performed by the same author to reduce variability. Evaluation of the repairs consisted of tensile strength testing and measurement of the gap formation and peak stresses. RESULTS Gap and peak stress for the two-strand modified Kessler repair were 0.30 +/- 0.15 N/mm2 and 1.03 +/- 0.51 N/mm2, respectively. For the Teno Fix repairs the mean gap and peak stress values were 0.80 +/- 0.46 N/mm2 and 1.19 +/- 0.12 N/mm2, respectively. The mean gap formation stress was significantly higher in the Teno Fix repairs than in the control repairs (p < .0005). There was no significant difference in peak strength between the repairs (p < .10). CONCLUSIONS The Teno Fix repair was superior to the modified Kessler repair. In the Teno Fix repairs, the gap formation stress was 67% of the peak tensile stress. In comparison, in the modified Kessler repairs, the gap formation stress was 29% of the peak stress. This can be correlated to the elastic property of the modified Kessler suture and the initial tightening of the suture around the tendon fibers. The Teno Fix system is nonelastic and is fully tensioned during installation. This lends to a more gap resistant repair.
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Affiliation(s)
- Nicky Lewis
- Investigation performed at the Surgical Learning Institute at Celebration Health Florida Hospital, Celebration, FL, USA.
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Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med 2003; 31:692-700. [PMID: 12975188 DOI: 10.1177/03635465030310051001] [Citation(s) in RCA: 182] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To study the effects of early weightbearing and ankle mobilization after acute repair of ruptured Achilles tendon. STUDY DESIGN Comparative longitudinal study. METHODS Patients in group 1 were postoperatively immobilized with their ankle in gravity equinus, they were encouraged to bear weight on the operated limb as soon as possible to full weightbearing, and they received a single cast change at 2 weeks, with the ankle accommodated in an anterior splint in a plantigrade position, allowing the ankle to be plantar flexed fully but not dorsiflexed above neutral. Patients in group 2 were immobilized with their ankle in full equinus with a cast change at 2 weeks, when the ankle was immobilized in mid equinus, and at 4 weeks, when the ankle was immobilized in a plantigrade position, and they were advised to bear weight. RESULTS Patients in group 1 attended fewer outpatient visits, completely discarded their crutches at an average of 2.5 weeks, and more were satisfied with the results of surgery. At ultrasonography, the average thickness of the repaired tendon was 12.1 mm, with no difference in the thickness of the ruptured tendon regardless of postoperative management. There was no significant difference in isometric strength between the two groups. CONCLUSIONS Early weightbearing with the ankle plantigrade is not detrimental to the outcome of repair after acute rupture of the Achilles tendon and shortens the time needed for rehabilitation. However, strength deficit and muscle atrophy are not prevented.
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Affiliation(s)
- Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, North Staffordshire Hospital, Hartshill, Stoke on Trent, Staffordshire, England
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Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med 2002; 30:565-75. [PMID: 12130412 DOI: 10.1177/03635465020300041701] [Citation(s) in RCA: 232] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is no consensus on the best method for management of acute Achilles tendon ruptures. Individual preferences, drawn from experience and study, determine whether treatment is operative or nonoperative. PURPOSE Our goal was to review the literature to try to determine what management method was the most popular and effective. We wanted to ascertain the best results in terms of complication rates and patient outcomes. STUDY DESIGN Retrospective review of retrospectively and prospectively collected data. METHODS We analyzed 125 articles in peer-reviewed journals for year of publication, patient numbers, sex, management method, follow-up complications, and patient satisfaction. Each article was graded using a validated methods score. Methods, patient satisfaction, and complication rates were correlated with the year each article was published. RESULTS Skin-healing complications were lowest in conservatively managed patients (3 of 578, 0.5%) and highest in open repair and immobilized patients (543 of 3718, 14.6%). General complication rates were lowest in open repair and early-mobilization groups (16 of 238, 6.7%) and highest in percutaneous and early-mobilization groups (19 of 122, 15.6%). Rerupture rates were highest in immobilized conservative management groups (62 of 578, 10.7%) and lowest in groups with external fixation (0%). CONCLUSIONS In general, the number of publications reporting Achilles tendon ruptures is increasing, the quality of articles is increasing, and the trend for the number of reported complications is decreasing. The published articles had a low methods score (mean, 50.9; range, 25 to 77) and showed a trend toward earlier mobilization. Open repair and early mobilization give the best functional recovery and an acceptable complication rate.
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Affiliation(s)
- Jason Wong
- Department of Orthopaedic Surgery, University of Aberdeen Medical School, Aberdeen, Scotland
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Abstract
Achilles tendon disorders are among the more common maladies seen by sports medicine physicians. Understanding the anatomy and biomechanics of the Achilles tendon and contiguous structures is essential to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achilles bursitis. Each of these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons should be treated operatively in most cases and result in predictably good outcomes. There may be some cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe functional deficit.
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Affiliation(s)
- Anthony A Schepsis
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts 02118, USA
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Akizuki KH, Gartman EJ, Nisonson B, Ben-Avi S, McHugh MP. The relative stress on the Achilles tendon during ambulation in an ankle immobiliser: implications for rehabilitation after Achilles tendon repair. Br J Sports Med 2001; 35:329-33; discussion 333-4. [PMID: 11579067 PMCID: PMC1724396 DOI: 10.1136/bjsm.35.5.329] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND After Achilles tendon repair, immediate weightbearing and immobilisation closer to neutral plantarflexion are thought to limit atrophy and stiffness, but may place deleterious stress on the repair. OBJECTIVES To estimate the relative stress on the Achilles tendon during weightbearing with immobilisation in varying degrees of plantarflexion. METHODS Electromyographic (EMG) activity from the plantarflexors was recorded during walking in 10 subjects (six men, four women) without ankle pathology. Four walking conditions were examined: (a) normal walking; (b) immobilised (cam-walker) in neutral plantarflexion; (c) immobilised with a 0.5 inch heel lift; (d) immobilised with a 1 inch heel lift. EMG activity relative to plantarflexor torque was determined for each subject during isometric contractions at 25%, 50%, 75%, and 100% of maximal voluntary contraction (MVC). EMG activity during walking was calculated as a percentage of MVC based on the EMG-torque relation during graded isometric contractions. RESULTS During normal walking, the plantarflexor torque was estimated to be 30 (12)% (mean (SD)) of MVC, compared with 21 (15)% MVC for immobilisation in neutral (p<0.05), 17 (15)% MVC with the addition of a 0.5 inch heel lift (p<0.01), and 12 (12)% MVC with the addition of a 1 inch heel lift (p<0.01). The 1 inch heel lift resulted in less than 10 degrees plantarflexion in all subjects. CONCLUSIONS When the ankle is immobilised, stress on the Achilles tendon is determined by the degree of plantarflexion and the contractile activity of the plantarflexors. In the immobilised ankle, the addition of a 1 inch heel lift was sufficient to minimise plantarflexor activity during walking.
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Affiliation(s)
- K H Akizuki
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, NY 10021, USA
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Aoki M, Oguma H, Fukushima S, Ishii S, Ohtani S, Murakami G. Fibrous connection to bone after immediate repair of the canine infraspinatus: the most effective bony surface for tendon attachment. J Shoulder Elbow Surg 2001; 10:123-8. [PMID: 11307074 DOI: 10.1067/mse.2001.111963] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The purpose of this histologic study was to identify the most effective bony surface for fibrous connection to bone after immediate repair of the canine infraspinatus. Light microscopic views were used to evaluate collagen fiber development. The left infraspinatus tendon of 15 dogs was transected and repaired to 3 different bone surfaces: a tendon end adjacent to the tendon insertion (group 1, n = 5), a calcified fibrocartilage layer (group 2, n = 5), and a cancellous surface (group 3, n = 5). Tendon repair to distal tendon ends restored the 4-layered enthesis in the healing period, whereas tendon repair to the calcified fibrocartilage layer considerably delayed fiber development into bone. Fiber connection to cancellous surface developed according to the remodeling of trabecular bone. Secure fiber connection into the thickened trabecular bone developed by 16 postoperative weeks. On the basis of these results, in clinical settings, ruptured tendon ends should be attached to the remaining distal tendon end or to a cancellous surface; they should not be attached to a calcified fibrocartilage layer.
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Affiliation(s)
- M Aoki
- Department of Physical Therapy, Sapporo Medical University School of Health Sciences, Japan
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