Intraoperative ultrasonography assistance for minimally invasive repair of the acute Achilles tendon rupture

Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis

Background

This systematic review and meta-analysis investigated the treatment for Achilles tendon rupture (ATR) associated with the lowest risk of rerupture in older patients.

Methods

Five databases were searched through September 2022 for studies published in the past 10 years analyzing operative and nonoperative ATR treatment. Studies were categorized as "nonelderly" if they reported only on patients aged 18-60 years. Studies that included at least 1 patient older than age 70 were categorized as "elderly inclusive." Of 212 studies identified, 28 were eligible for inclusion. Of 2965 patients, 1165 were treated operatively: 429 (37%) from elderly-inclusive studies and 736 (63%) from nonelderly studies. Of the 1800 nonoperative patients 553 (31%) were from nonelderly studies and 1247 (69%) were from elderly-inclusive studies.

Results

For nonoperative treatment, the rate of rerupture was higher in nonelderly studies (83/1000 cases, 95% CI = 58, 113) than in elderly-inclusive studies (38/1000 cases, 95% CI = 22, 58; P<.001). For operative treatment no difference was found in the rate of rerupture between nonelderly studies (7/1000 cases, 95% CI = 0, 21) and elderly-inclusive studies (12/1000 cases, 95% CI = 0, 35; P<.78). Overall, operative treatment was associated with a rerupture rate of 1.5% (95% CI: 1.0%, 2.8%) (P<.001), which was lower than the 5% rate reported by other studies for nonoperative management (P<.001).

Conclusion

Older patients may benefit more than younger patients from nonoperative treatment of ATR. More studies are needed to determine the age at which rerupture rates decrease among nonoperatively treated patients.

Level of Evidence

3.

Modified Minimally Invasive Bunnell Suture Surgery with Channel-assisted Minimally Invasive Reconstruction Device for Treating Achilles Tendon Rupture

The aim of this study was to improve the process of microincision and endoscopic surgery for the treatment of Achilles tendon (AT) rupture using the modified minimally invasive Bunnell suture (MIBS) technique.From December 2019 to December 2021, 20 patients with AT rupture who visited the First Affiliated Hospital of Harbin Medical University (Harbin, China) underwent MIBS surgery.A total of 20 patients were included, of whom 18 (90.0%) were male and 2 (10.0%) were female. The mean age of the patients was 37.75 ± 9.94 years. In terms of the site of the AT, two (10.0%) had surgery on their left AT. The mean duration of surgery was 23.00 ± 2.47 minutes, and the mean bleeding volume was 5.00 ± 1.12 mL. All 20 patients (100%) showed complete incisional healing (stage I healing) and normal functional recovery (3-6 months postoperatively). There were no cases of abnormal functional recovery or postoperative recurrence within the 3-6 month follow-up period. The Achilles tendon Total Rupture Score (ATRS) significantly improved post-surgery (83.6 ± 5.59) compared to pretreatment (0.3 ± 0.92, p < 0.0001), indicating successful patient recovery.After the modified MIBS surgical process, the operation steps were simplified, the surgical difficulty was reduced, and the surgical trauma was alleviated, resulting in good postoperative recovery and patient satisfaction with the outcome. Therefore, the MIBS surgery has high promotability.

Percutaneous cruciate repair of ruptured Achilles tendon

Percutaneous repair is a safe and reliable method to restore continuity after acute Achilles tendon ruptures, with a lower incidence of wound complications compared to open techniques. We describe a novel percutaneous cruciate suture performed through 5 stab skin incisions, four of which are longitudinal and parallel to the course of the sural nerve to minimize the risk of injury and one transverse incision at the site of rupture, with a total of 16 suture threads and the knot outside the tendon body, increasing the tensile strength of the suture and minimizing the risk of re-rupture. Clinical studies are necessary to ascertain whether the theoretical advantages of the cruciate suture technique translate into better clinical outcomes compared to established percutaneous techniques.

Positional relationship between the Achilles tendon and sural nerve on ultrasound

PURPOSE

This study sought to clarify the positional relationship between the Achilles tendon and sural nerve using ultrasound.

METHODS

We studied 176 legs in 88 healthy volunteers. The positional relationship between the Achilles tendon and sural nerve at heights of 2, 4, 6, 8, 10, and 12 cm proximal from the calcaneus' proximal margin was investigated by distance and depth. Setting the X-axis (left/right) as the horizontal axis and Y-axis (depth) as the vertical axis against ultrasound images, we investigated the distance between the lateral margin of the Achilles tendon to the midpoint of the sural nerve on the X-axis. The Y-axis was split into four zones: the part behind the center of the Achilles tendon (AS), the part in front of the center of the Achilles tendon (AD), the part behind the Achilles tendon (S), and the part in front (D). We investigated the zones through which the sural nerve passed. We also studied any significant differences between the sexes and left/right legs.

RESULTS

The mean distance on the X-axis was closest at 6 cm, with 1.1 ± 5.0 mm between them. The sural nerve's position on the Y-axis was such that at positions more proximal than 8 cm, the sural nerve ran through zone S in most legs and moved to zone AS through heights 2-6 cm. No parameters showed significant differences between the sexes or left/right legs.

CONCLUSION

We presented the positional relationship between the Achilles tendon and sural nerve and suggested some measures to prevent nerve injury during surgery.

Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.

Application of Preoperative Ultrasonography in the Percutaneous Minimally Invasive Repair of Acute Closed Achilles Tendon Rupture

Percutaneous minimally invasive surgery involving Achilles tendon (AT) repair has the advantages of a low rerupture rate and fewer postoperative complications. However, due to the inability to operate under direct vision, the injury of the small saphenous vein (SSV) and sural nerve (SN) remains largely a high risk involving many challenges. We propose to introduce the preoperative application and advantages of ultrasonography in percutaneous minimally invasive surgery for acute AT rupture. Our results indicated that ultrasonography could locate the position of the SN more accurately and reduce the risk of iatrogenic nerve injury. Compared with the traditional surface markers, the preoperative localization and marking of AT, SSV, and SN in ultrasonography significantly reduced the risk of intraoperative accidental injury to blood vessels and nerves, which could reduce postoperative complications and promote early rehabilitation of patients. We ultimately exploit the properties of ultrasonography in percutaneous minimally invasive surgery to treat Achilles tendon rupture.

Ultrasound evaluation of a new surface reference line to describe sural nerve location and safe zones to consider in posterior leg approaches

PURPOSE

Several authors have described methods to predict the sural nerve pathway with non-proportional numerical distances, but none have proposed a person-proportional, reproducible method with anatomical references. The aim of this research is to describe ultrasonographically the distance and crossing zone between a surface reference line and the position of the sural nerve.

METHODS

Descriptive cross-sectional study, performed between January and April 2022 in patients requiring foot surgery who met inclusion criteria. The sural nerve course in the posterior leg was located and marked using ultrasound. Landmarks were drawn with a straight line from the medial femoral condyle to the tip of the fibula. Four equal zones were established in the leg by subdividing the distal half of the line. This way, areas based on simple anatomical proportions for each patient were studied. The distance between the marking and the ultrasound nerve position was measured in these 4 zones, creating intersection points and safety areas. Location and distances from the sural nerve to the proposed landmarks were assessed.

RESULTS

One-hundred and four lower limbs, 52 left and 52 right, assessed in 52 patients were included. The shortest median distance of the nerve passage was 2.9 mm from Point 2. The sural nerve intersection was 60/104 (57.7%) in Zone B, 21/104 (20.1%) in Zone C and 19/104 (18.3%) in Zone A. Safety zones were established. Average 80.5% of coincidence in sural nerve localization was found in the distal half of the leg, in relation to the surface reference line when comparing both legs of each patient.

CONCLUSIONS

This study proposes a simple, reproducible, non-invasive and, for the first time, person-proportional method, that describes the distance and location of the main areas of intersection of the sural nerve with points and zones (risk and safe zones) determined by a line guided by superficial anatomical landmarks. Its application when surgeons plan and perform posterior leg approaches will help to avoid iatrogenic nerve injuries.

LEVEL OF EVIDENCE

IV.

The modified mini-open technique for repairing total ruptured Achilles tendon using fiber wire with calcaneal fixation. A prospective case series

Background

The purpose of this study was to evaluate clinical outcomes and complications of our modified Maffuli's mini-open technique for repairing acute Achilles tendon rupture using fiber wire and calcaneal fixation.

Material and methods

Between January 2017 and August 2020, 21 patients with acute rupture of the Achilles tendon who underwent the modified mini-open Maffulli's procedure have been enrolled in the study.

Result

All surgical incisions healed well without scar adhesions or infections. One year postoperatively, the ATRS score and AOFAS score were 91.2 ± 1.8; 97.2 ± 1.6 respectively; the range of ankle joint movement was normal. Patients could return to their work and their light sporting activities at the time of 16.9 ± 1.1 weeks and 19.7 ± 0.9 weeks postoperatively, respectively. 21 out of 21 patients were able to perform single heel raise. There were no sural nerve injuries, re-ruptures, tendon elongation, or deep vein thromboses.

Conclusion

We have shown that the modified Maffulli's technique using fiber wire with a calcaneal fixation for repairing acute Achilles tendon ruptures to be a safe and reliable method without requiring specialized or expensive materials. It allows a durable repairing, a limitation of healing problems, and a quick return to physical therapy and full activity. This technique can be widely employed in a low-income country.

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The best treatment for acute Achilles tendon rupture is not defined.

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The modified Maffulli's technique using fiber wire with a calcaneal fixation is a safe and reliable method.

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It allows durable repairing, a limitation of wound healing problems, and a quick return to physical therapy.

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This technique can be widely employed in a low-income country.

Anatomical study for the treatment of proximal humeral fracture through the medial approach

BACKGROUND

The treatment of complex 3- and 4-part proximal humeral fractures has been controversial due to numerous postoperative complications. With the further study of medial support and blood supply of humeral head, new techniques and conception are developing. The study aims to illustrate the medial approach of the proximal humeral fracture through cadaver autopsy.

METHOD

Upper limbs from 19 cadavers have been dissected to expose the shoulder joint. We selected the coracoid process as the bony reference. Vernier caliper will be used to measure the following data, including distance from coracoid process to circumflex brachial artery, distance between anterior humeral circumflex artery (ACHA) and posterior circumflex brachial artery (PCHA) and their diameters. Assessment included the characteristics of the vascular supply around the humeral head, identification of the structures at risk, quality of exposure of the bony structures, and feasibility of fixation.

RESULTS

The medial approach is appropriate in 86.84% anatomical patterns. Between the lower part of the shoulder capsule and the insertion of conjoined tendon, the bony surface exposed was limited by the interval between ACHA and PCHA. An interval of 2 to 3 cm (24.29 ± 3.42 mm) was available for medial plate. ACHA (49.35 ± 8.13 mm, 35.14-68.53 mm) and PCHA (49.62 ± 7.82 mm, 37.67-66.76 mm) were about 5 cm away from the coracoid process. Risk structures including ACHA and PCHA originate in common, PCHA originated from the deep brachial artery (DBA), the presence of perforator vessels, musculocutaneous nerve intersects with ACHA, the diameter of PCHA: ACHA < 1.5. In 13.15% anatomical patterns, this risk structure should be taken seriously.

CONCLUSION

The medial approach opens a new perspective in the optimal management of complex fractures of proximal humerus. Anatomical research proves that the medial approach is feasible. The interval between ACHA and PCHA is suitable for placement. Anatomical pattern and indication have been discussed, and we hypothesized that ACHA has been destroyed in complex PHFs. With further studies on the anatomy and mechanism of injury, the development of more clinical cases will be an important work of our institution in the future.

Augmented Repair of Acute Total Achilles Tendon Rupture With Peroneus Brevis Tendon Transfer Using Oblique Transosseous Calcaneal Tunnel: A Prospective Case Series

Acute Achilles tendon rupture is one of the most common tendon injuries. This prospective study aimed to evaluate the functional outcomes of augmented repair of acute Achilles tendon rupture with peroneus brevis tendon transfer and fixation to an oblique calcaneal transosseous tunnel. Functional evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS). Postoperative complications were recorded. This study included 33 males and 9 females, with a mean age of 26.1 ± 4.2 years. The Achilles tendon ruptures were right in 24 patients and left in 18 patients. The cause of rupture was sports injuries in all patients. The mean distance from the calcaneal insertion to the tear site was 4.4 ± 1.3 cm. The mean time from injury to surgery was 2.4 ± 1.6 days. The mean follow-up time was 40.3 ± 4.9 months. The mean AOFAS and ATRS scores were 99.3 ± 1.2 and 95.9 ± 1.9, respectively, at 12 months of follow-up. The mean time to return to work was 12.1 ± 1.2 weeks. The mean time to return to light sports activities was 16.1 ± 1.8 weeks postoperatively. None of the patients developed re-rupture. Augmented repair of acute Achilles tendon ruptures with peroneus brevis tendon transfer is a robust repair with excellent functional outcomes and early weight-bearing and return to sports activities.