Achilles tendon repair with an absorbable polymer-carbon fiber composite

Surgical repair of symptomatic chronic achilles tendon rupture using synthetic graft augmentation

BACKGROUND

Surgical repair of symptomatic chronic Achilles tendon (TA) rupture is a challenging problem due to the presence of a large defect between tendon edges. We report the results of surgical repair of symptomatic chronic TA rupture by synthetic graft augmentation.

METHODS

Seven consecutive patients with a symptomatic chronic TA rupture underwent surgical repair by VY plasty and augmentation with bio-absorbable synthetic graft (Artelon^®). In all patients, the intraoperative tendon gap after debridement was more than 5cm (Myerson Grade 3). The total duration of plaster immobilization was 10 weeks. The complications were recorded prospectively and functional outcome was assessed by AOFAS score and Achilles tendon Total Rupture Score (ATRS).

RESULTS

At a mean follow up of 29 months there was no re-rupture or deep infection. All patients reported good functional outcome as shown by AOFAS and ATRS scores. There were no graft related complications. At final follow up, six patients were able to do single stance heel raise however, calf wasting was noted in all patients.

CONCLUSIONS

Tendon repair augmented by absorbable synthetic graft is an acceptable technique in Myerson Grade 3 chronic symptomatic TA ruptures.

LEVEL OF EVIDENCE

Level IV, Case series.

Surgical treatment of the neglected achilles tendon rupture with Hyalonect

BACKGROUND

The purpose of this study was to report the management and outcomes of ten patients with chronic Achilles tendon rupture treated with a turndown gastrocnemius-soleus fascial flap wrapped with a surgical mesh (Hyalonect).

METHODS

Ten men with neglected Achilles tendon rupture were treated with a centrally based turndown gastrocnemius fascial flap wrapped with Hyalonect. Hyalonect is a knitted mesh composed of HYAFF, a benzyl ester of hyaluronic acid. The Achilles tendon ruptures were diagnosed more than 1 month after injury. The mean patient age was 41 years. All of the patients had weakness of active plantarflexion. The mean preoperative American Orthopaedic Foot and Ankle Society score was 64.8.

RESULTS

The functional outcome was excellent. The mean American Orthopaedic Foot and Ankle Society score was 97.8 at the latest follow-up. There were significant differences between the preoperative and postoperative scores. Ankle range of motion was similar in both ankles. Neither rerupture nor major complication, particularly of wound healing, was observed.

CONCLUSIONS

For patients with chronic Achilles tendon rupture with a rupture gap of at least 5 cm, surgical repair using a single turndown fascial flap covered with Hyalonect achieved excellent outcomes.

Acute achilles tendon rupture in athletes

The incidence of AT rupture has increased in recent decades. AT ruptures frequently occur in the third or fourth decade of life in sedentary individuals who play sport occasionally. Ruptures also occur in elite athletes. Clinical examination must be followed by imaging. Conservative management and early mobilization can achieve excellent results, but the rerupture rate is not acceptable for the management of young, active, or athletic individuals. Open surgery is the most common option for AT ruptures, but there are risks of superficial skin breakdown and wound problems. These problems can be prevented with percutaneous repair.

Surgical reconstruction of chronic achilles tendon ruptures using various methods

The purpose of this study was to evaluate the surgical outcomes of reconstruction of chronic Achilles tendon ruptures using various methods, including Achilles tendon allograft. Between October 2003 and March 2010, twelve patients with chronic Achilles tendon ruptures and a defect gap of >4 cm underwent surgical reconstruction with V-Y advancement, gastrocnemius fascial turn-down flap, flexor hallucis longus tendon transfer, or Achilles tendon allograft. The study group comprised 11 men and 1 woman. At last follow-up, all patients were assessed with regard to postoperative complications, self-reported level of satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score, repetitive single-heel rises, single-leg hopping test, and ankle range of motion. The AOFAS scores increased from an average of 68.7 (range, 50-87) preoperatively to 98.0 (range, 88-100) postoperatively. All patients were able to perform 10 repetitive single-heel raises and single-leg hops at last follow-up. No patient experienced wound complications or deep infection. Seven patients were rated as excellent, 4 as good, and 1 as fair. Chronic Achilles tendon ruptures can be successfully treated by careful selection of the reconstruction method according to the length of defect gap and state of the remaining tissue. With an extensive defect, use of an Achilles tendon allograft can be a good option.

Acute ruptures of the achilles tendon

The Achilles tendon (AT) is the most frequently ruptured tendon in the human body, but the etiology of AT ruptures is still not completely understood. Percutaneous repair and conservative management are viable alternatives to open surgery, which carries higher complication rates and is the most costly of the 3 management options. Individual patients will have different needs due to their age, occupation, or level of sporting activity. If the studies reporting a rising incidence of AT rupture are accurate, the field of AT surgery will become an increasingly important one for orthopedic surgeons. A major problem in the evaluation of the outcome of management of AT ruptures has been the lack of a universally accepted scoring system for the evaluation of results of management of AT rupture. The AT Total Rupture Score is a self-administered instrument with high clinical utility, and it can be used for measuring the outcome, related to symptoms and physical activity, after treatment in patients with a total AT rupture. Future developments may include the use of adhesives in tendon surgery. An understanding of the role, which cytokines play in tendon healing may also lead to the advent of new treatments, possibly based on gene therapy. However, such novel interventions are unlikely to be in routine clinical use for some time.

Tendon disorders of the foot and ankle, part 2: achilles tendon disorders

Disorders of the Achilles tendon include both acute and chronic ruptures as well as a spectrum of chronic overuse injuries involving inflammatory and degenerative changes within the tendon and surrounding tissues. These injuries are relatively common in athletes as well as among the general population. There is no consensus on the optimal treatment of Achilles tendon disorders. The goals of this review are to develop a current understanding of the anatomy and diagnostic evaluation of the Achilles tendon, and to present current treatment options and the authors' preferred surgical techniques for operative management of Achilles tendon disorders.

The strength of the 6-strand modified Kessler repair performed with triple-stranded or triple-stranded bound suture in a porcine extensor tendon model: an ex vivo study

PURPOSE

To investigate the biomechanic influence of triple-stranded sutures and the spatial arrangement of the strands on the strength of the 6-strand Pennington modified Kessler repair.

METHODS

In the present ex vivo study of pig extensor tendons 2 techniques were used: (1) triple-stranded suture (3 suture strands in the same needle) and (2) triple-stranded bound suture (3 suture strands in the same needle that were bound together, parallel to each other, side by side). The repairs were subjected to static tensile testing.

RESULTS

The 6-strand modified Kessler repair performed with triple-stranded bound suture reached significantly higher yield force, ultimate force, and both partial and total 1-, 2-, and 3-mm gap forces compared with the repairs performed with triple-stranded suture. The stiffness and strain values at the yield point and at the ultimate point did not differ significantly.

CONCLUSIONS

This experimental study introduces a way to improve the strength of the tendon repair. The triple-stranded bound suture significantly increased both the gap resistance and ultimate force of the 6-strand modified Kessler repair. We assume the improvements are due to increased holding capacity of the locking loops. The triple-stranded bound suture is easy to use and avoids several problems associated with traditional multistrand repairs. Further studies are needed before clinical use can be considered.

Acute rupture of the Achilles tendon

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.

Quantitative review of operative and nonoperative management of achilles tendon ruptures

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.

Subcutaneous rupture of the Achilles tendon: basic science and some aspects of clinical practice

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Repair of neglected Achilles tendon ruptures with a triceps surae muscle tendon advancement

Neglected Achilles tendon ruptures, although rare, can be a surgical challenge for the lower extremity specialist. These injuries often present with large defects which require special reconstructive techniques and principles. This paper presents an overview of this problem, various treatment strategies, and two case reports utilizing a triceps surae muscle tendon flap advancement.

Neglected rupture of the Achilles tendon

Delayed treatment of a rupture of the Achilles tendon is a challenge. Operative treatment is generally recommended, with a variety of techniques being described to appose the tendinous ends and augment the repair.

Management of traumatic tendon lacerations

This article deals with the diagnosis and treatment of tendon lacerations. Tendon healing, with its implications relative to treatment, is discussed. The various pros and cons of suturing severed tendons are addressed as well as methods of immobilizing the injured limb. The need for prompt diagnosis and aggressive treatment of tendon sheath injuries is also discussed.

Long-term follow-up of achilles tendon repair with an absorbable polymer carbon fiber composite

In this cooperative multicenter study for surgical repair of Achilles tendon rupture using a composite implant, 48 patients underwent 52 procedures. This implant is composed of filamentous uniaxially aligned carbon fibers coated with an absorbable polymer. This highly biocompatible implant acts as a scaffold for regrowth of collagenous tissue. The early strength of this repair is provided by the composite implant and by the rapid ingrowth and attachment of new tissue, which allows for an earlier and more vigorous rehabilitation program. Patients with a minimum follow-up of 1 year form the basis of this article. The overall average follow-up is 2.1 years. Three cohort groups were observed on a temporal basis and quantitatively evaluated at 1 year (N = 29), 18 months (N = 22), and 2 years (N = 20), respectively. These three groups demonstrated continuous improvement during the first postoperative year. A high level of function was maintained throughout the second year. Repair of chronic injuries (N = 15) was compared with repair of acute injuries (N = 12) at 1 year following surgery. Both groups greatly improved. However, the acute group had more serious preoperative deficits but improved to a slightly better overall level. Of the patients having at least 1 year follow-up, 86% had a good or excellent result. There was no increased morbidity associated with the use of the carbon implant.

Resorbable materials and composites. New concepts in orthopedic biomaterials

For the last several decades, research in orthopedic biomaterials has remained focused on homogeneous plastics and metals. Initial research resulted in rapid improvements and a number of standardized materials emerged. With time, development of these materials has become a slower, more deliberate process. Recently, however, investigators have sought to broaden the scope of orthopedic biomaterials research. New materials systems are now under consideration. These systems include natural and synthetic resorbable polymerics and resorbable ceramics. A variety of composite materials are under primary investigation or in clinical trials. Our emerging understanding of these new materials is rapidly leading to new surgical applications not possible with conventional metals and plastics.