Repair of distal tendo Achillis rupture with the use of the Mitek Anchor System

Calcaneal Tuberosity Fracture With Complete Achilles Tendon Rupture: A Unique Surgical Challenge

A calcaneal tuberosity avulsion fracture occurring simultaneously with a rupture of the Achilles tendon, although occurring through similar mechanisms, is a rare injury pattern to see in combination and presents a unique challenge to the surgeon. The patient we present was initially found to have a type II fracture of the calcaneal tuberosity. However, during surgical fixation of the fracture, a complete rupture of the Achilles tendon was noticed. The technique used in this case was the fixation of the fracture fragment with two 5 mm fully threaded screws. The tendon was then reattached to the calcaneus using two Mitek anchors (DePuy Mitek Inc., MA, USA) with a modified Bunnell technique. There are a number of techniques suggested in the literature, including, among others, K-wires (DePuy Mitek Inc., MA, USA) and screw fixation. Our patient recovered well and has now been discharged from further orthopaedic follow-up.

Repair of Achilles sleeve avulsion: a new transosseous suture technique

BACKGROUND

Achilles sleeve avulsion usually occurs from pre-existing insertional Achilles tendinopathy, leaving a calcific spur at the insertional site. The purpose of this study was to introduce a new technique using the spur base on the insertional site to drill the suture tunnel to repair Achilles sleeve avulsion.

METHODS

In total, 11 patients diagnosed with Achilles sleeve avulsion underwent this new surgical technique and were followed for a mean time of 40 months. Clinical outcomes were measured using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Tegner score, and time taken to return to activities. Preoperative and postoperative MRI, the ability to perform heel rise, and complications were also evaluated.

RESULTS

All cases (11/11) had insertional Achilles tendinopathy with calcific spur formation on the tendon's insertion. At final follow-up, the average VAS score improved from 5.3 to 0.1, AOFAS score improved from 44.8 to 97.9, VISA-A score improved from 23.6 to 96.6, and Tegner score improved from 0.9 to 4.9. Tendinopathy symptoms were eliminated. Patients returned to daily activities, work, and sports 3.5 months, 2.8 months, and 12.3months after operation, respectively. Patients took an average of 18.1 weeks after operation to perform the single heel rise test. No severe complications such as infection and rerupture were observed.

CONCLUSION

Our new transosseous suture technique is a promising alternative option in treating Achilles sleeve avulsion. More cases and longer follow up are needed in order to find the best reconstructive option for this pathology.

LEVELS OF EVIDENCE

Level IV.

Characterization and Surgical Management of Achilles Tendon Sleeve Avulsions

BACKGROUND

An Achilles sleeve avulsion occurs when the tendon ruptures distally from its calcaneal insertion as a continuous "sleeve." This relatively rare injury pattern may not be appreciated until the time of surgery and can be challenging to treat because, unlike a midsubstance rupture, insufficient tendon remains on the calcaneus to allow for end-to-end repair, and unlike a tuberosity avulsion fracture, any bony element avulsed with the tendon is inadequate for internal fixation. This study aimed to highlight the characteristics of Achilles sleeve avulsions and present the outcomes of operative repair using suture anchor fixation.

METHODS

A retrospective analysis was conducted on 11 consecutive Achilles tendon sleeve avulsions (10 males, 1 female; mean age 44 years) that underwent operative repair between 2008 and 2014. Patient demographics, injury presentation, and operative details were reviewed. Postoperative outcomes were collected at a mean follow-up of 38.4 (range, 12-83.5) months, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, visual analog scale (VAS) for pain, plantarflexion strength, patient satisfaction, and complications.

RESULTS

Eight patients (72.7%) had preexisting symptoms of insertional Achilles disease. Ten of 11 (90.9%) injuries were sustained during recreational athletic activity. An Achilles sleeve avulsion was recognized preoperatively in 7 of 11 (64%) cases, where lateral ankle radiographs demonstrated a small radiodensity several centimeters proximal to the calcaneal insertion. Intraoperatively, 90.9% of sleeve avulsions had a concomitant Haglund deformity and macroscopic evidence of insertional tendinopathy. All patients healed after suture anchor repair. The average AOFAS score was 92.8 and VAS score was 0.9. Ten patients (90.9%) were completely satisfied. One complication occurred, consisting of delayed wound healing.

CONCLUSIONS

Achilles tendon sleeve avulsions predominantly occurred in middle-aged men with preexisting insertional disease, while engaged in athletic activity. Suture anchor fixation, combined with addressing concomitant insertional pathology, was a reliable and safe technique for the operative management of Achilles tendon sleeve avulsions. The majority of patients returned to their preinjury levels of work and recreational activity.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A case report of periprosthetic fracture left proximal humerus with radial nerve palsy following pectoralis major repair

Primary repair of pectoralis major tendon with bony tunnels and anchor sutures in the proximal humerus creates a potential weakness and stress riser leading to increased risk of periprosthetic fracture and nerve damage at the site of weakness with subsequent injury, if not allowed to heal satisfactorily with adequate period of rest.

Repair of Achilles tendon rupture using autologous semitendinosus graft in a kidney transplant recipient

Insertional Achilles tendon injuries can be difficult to treat when minimal tendon tissue remains for anastomosis. Moreover, in the chronic case with tendon shortening, operative repair can be more difficult than acute rupture. It is particularly desirable to reinforce the tendons, in addition to performing primary repair, in patients with renal or systemic diseases because of the accelerated collagen degeneration. Many techniques have been described for the surgical management of Achilles tendon rupture; however, none has shown clear superiority. We report the case of a 50-year-old renal transplant patient with a spontaneous distal Achilles tendon injury that we repaired using the pull-out technique reinforced with an autologous semitendinosus graft. At 2 years postoperatively, the ankle-hindfoot scale score was 92 points, and the postoperative course was without complication. We believe that the free hamstring tendon autograft is advantageous for this repair, because it is easy to handle, has limited donor site morbidity, and preserves the structures around the ankle.

Suture anchor tenodesis in repair of distal Achilles tendon injuries

BACKGROUND

Distal Achilles tendon avulsions are in the form of either bony and nonbony avulsion of Achilles tendon from its calcaneal insertion.

METHODS

Four patients with distal Achilles tendon avulsions or ruptures which were treated with tendon to bone repair using suture anchors are presented here. Operated leg was immobilized in above-knee cast for 4 weeks while the patient walked non-weight-bearing. Then, cast was changed to below knee, and full weight-bearing was allowed. Patients underwent gait analysis minimum at first postoperative year.

RESULTS

Mean American Orthopedics Foot Ankle Society ankle/hindfoot score of patients at last visit was 88.75 (range 85-100), and Achilles tendon total rupture score was 77.75 (range 58-87). Mean passive dorsiflexion of injured ankles (14° ± 5°) was lower than uninjured ankles (23° ± 9°). All the kinematic parameters of gait analysis were comparable to the uninjured side. Maximum plantar flexion power of injured ankle was 1.40 W/kg, and this was significantly lower than the contralateral side value 2.38 W/kg; (P = 0.0143).

CONCLUSIONS

There were no visually altered gait or problems in daily life. Suture anchor tenodesis technique of distal Achilles tendon avulsions was successful in achieving durable osteotendinous repairs.

Fixation of tendo Achilles avulsion fracture

Achilles tendon ruptures occur commonly in the midsubstance of the tendon, usually 2-6 cm proximal to the insertion to the calcaneus. Ruptures near its insertion into the calcaneus are less common and mostly found in hyperpronators with a heel spur (Haglund's deformity). Avulsion of the bony insertion of the Achilles tendon at the calcaneus is infrequent and is diagnosed by radiography. Open reduction and internal fixation is indicated to achieve bone to bone healing and restoration of the function and continuity of the triceps surae mechanism. Screw fixation is not effective to resist the pull out tension of the triceps surae. Moreover, the prominent screw head may cause skin impingement. More secure fixation method is necessary in order to allow early functional rehabilitation. We describe a technique to fix the avulsed fragment of Achilles tendon insertion with 2 suture anchors. This can neutralize the pull of the triceps surae and early post-operative rehabilitation programme is allowed.

Clinical application of prong-type tissue anchors in small animal surgery

Prong-type tissue anchors were used in six dogs and one cat in a variety of orthopaedic procedures in order to aid repair and replacement of tendons and ligaments. All animals returned to normal function with minimal problems.

Traumatic hallux varus repair utilizing a soft-tissue anchor: a case report

Hallux varus is usually iatrogenic in nature; however, congenital and acquired etiologies have been described in the literature. The authors present a case of traumatic hallux varus secondary to rupture of the adductor tendon. Surgical correction was performed using a soft tissue anchor for maintenance of the soft tissues utilized for repair.

Spiked metallic washer and screw for reattachment of the Achilles tendon after repair of a distal rupture

The authors review Achilles tendon ruptures and treatment options for the acute and chronic rupture. A case is described involving reattachment of a chronic distal Achilles tendon rupture repair with a spiked metal washer and fully threaded cannulated cancellous screw. Spiked metal washers and their effects on soft-tissue pullout strength, and possible complications are discussed. In review of the literature, the authors have not found this type of fixation used to anchor the Achilles tendon, and feel it may be a viable option when faced with distal Achilles reattachment for the acute and chronic rupture.

Titanium anchors for the repair of distal Achilles tendon ruptures: preliminary report of a new surgical technique

From January 1995 to July 1996, the authors used Mitek GIV titanium anchors to treat seven patients with acute rupture of the Achilles tendon (four men, three women; average age 52.42 years; range, 33-62 years). All subjects had a total rupture of the most distal aspect of the tendon; none had an avulsion fracture. After dissection down to the paratenon, the reinsertion site was selected and a 2 to 3-cm-long trough carved through the cortex. Three holes were drilled at a distance of 0.5 cm one from the other and 1 cm parallel and distal to the trough. The anchors were then threaded, inserted into the holes, and engaged. Surgery was completed by resection of the frayed ends, reparation of the tendon, and insertion of the terminal end into the trough. At 6 months postoperative, a modified Mandelbaum and Pavanini clinical assessment indicated five excellent and two good outcomes. There were no cases of deep of superficial wound infection or skin necrosis. Despite the small number of patients and the short follow-up period, the authors believe this technique shows promise and that in selected cases the use of titanium anchors can facilitate the task of the surgeon and enable patients to return to normal and sports activities within 5 months after surgery.

Modified Kidner procedure utilizing a Mitek bone anchor

The recent development of small bone suture anchors has created several potential applications in reconstructive surgery of the foot. Mitek bone anchors are simple to insert, require less aggressive dissection and surgical time than reefing of the redundant posterior tibial tendon, and are a reliable method of tendon-to-bone fixation. Mitek bone anchors are an excellent technique for the treatment of redundant tibialis posterior tendon following a modified Kidner procedure. In modified Kidner procedures involving an excessively large os tibiale externum, Mitek anchoring of the redundant tibialis posterior tendon to the navicular bone is an excellent means for secure plication of the posterior tibial tendon in cases involving intraoperative tendon laxity. A description of the Mitek Anchor System and technique of application in a modified Kinder procedure is presented. The purpose of this study was to describe patient satisfaction and long-term clinical outcomes of the modified Kinder procedure with and without the Mitek bone anchoring system. A retrospective study of the modified Kinder procedure was performed with 13 patients being evaluated, seven with Mitek anchoring and six without. The University of Maryland 100-point Painful Foot Center Scoring System was modified to be more specific to the modified Kinder procedure for assessment of subjective long-term results. Patient overall satisfaction was rated good to excellent by 85.6% of patients in the Mitek group and by 100% of patients in the non-Mitek group. Use of the Mitek anchor allowed for quicker postoperative recovery to resumption of ambulation without assistive devices (average of 3 weeks vs. 4.42 weeks) and a quicker return to pain-free ambulation in normal shoegear (average of 4 weeks vs. 6 weeks). Mitek anchoring of the tibialis posterior tendon, theoretically, increases medial arch support as evidenced by 14% of the Mitek group and 67% of the non-Mitek group requiring postoperative orthotics.