Open and Percutaneous Approaches Have Similar Biomechanical Results for Primary Midsubstance Achilles Tendon Repair: A Meta-analysis
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SUBMITTER: Lawson J
PROVIDER: S-EPMC11240046 | biostudies-literature | 2024 Mar
REPOSITORIES: biostudies-literature
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Project description:BackgroundTo reduce incision complications, minimally invasive operative approaches for treatment with acute Achilles tendon rupture have been developed, such as Mini-open repair and percutaneous repair. Which technique is the better surgical option? In the present study, we compared the two surgical procedures- modified Mini-open repair versus percutaneous repair-in the treatment of acute Achilles tendon rupture.MethodsFrom January 2016 to November 2018, 68 matched patients with acute Achilles tendon rupture were divided into treatment group (Mini-open with modified Ma-Griffith technique) and control group (the Ma-Griffith technique). The patients were then treated with different surgical techniques and followed up for no less than 24 months, and the functional outcome scores and complications were retrospectively evaluated.ResultsThe mean follow-up time in Mini-open repair group was 29.0±2.9 months, and that in control group was 27.9±2.9 months (P=0.147). The Mini-open repair group showed reliably higher American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Achilles tendon Total Rupture Score (ATRS) than the control group in functional assessment (95.0±3.8 vs. 92.3±5.3, P=0.000; 93.8±3.8 vs. 90.9±4.5,P=0.000). There was no cases of sural nerve injury in Mini-open repair group, whereas the percutaneous repair group had 5 cases of the same (P=0.027). No significant differences were found in the calf circumference (32.3±3.9 vs. 31.8±3.6) (P=0.564), range of motion of the ankle (51.3±4.8 vs. 50.5±4.2, P=0.362), or wound complications (34/0 vs. 34/0) (P=1.000) between the two groups at the end of the follow-up time. However, the percutaneous repair group had a shorter average operating time (23.1±5.2 min) than that of the Mini-open repair group (27.7±4.3 min) (P=0.000).ConclusionsAcute Achilles tendon ruptures may be treated successfully with a new Mini-open repair system or percutaneous repair technique. However, the Mini-open repair system may represent a superior surgical option, since it offers advantages in terms of direct visual control of the repair, AOFAS Ankle-Hindfoot Score, Achilles tendon Total Rupture Score and risk of sural nerve palsy.Study designCase-control studies, Level of evidence, 3.
| S-EPMC8556965 | biostudies-literature
Project description:BackgroundPercutaneous repair of acute Achilles tendon rupture (ATR) continues to gain in popularity. The primary aim of the study was to review the outcomes of a patient cohort undergoing a novel technique of endoscopic percutaneous Achilles tendon repair with absorbable suture. A secondary purpose of this study was to evaluate the basic biomechanical properties of the technique.MethodsA cohort of 30 patients who underwent percutaneous ATR repair was retrospectively analyzed with Achilles Tendon Rupture Scores (ATRS), complications, and additional outcome measures. For a biomechanical analysis portion of the study, 12 cadaveric specimens were paired and randomized to either novel percutaneous repair or open Kessler repair with absorbable suture. These specimens were subjected to 2 phases of cyclical testing (100 cycles 10-43 N followed by 200 cycles 10-86 N) and ultimate strength testing.ResultsIn the clinical portion of the study we report excellent patient reported outcomes (mean ATRS 94.1), high level of return to sport, and high patient satisfaction. One partial re-rupture was reported but with no major wound or neurologic complications. In the biomechanical portion of the study we found no significant difference in tendon gapping between percutaneous and open repairs in phase 1 of testing. In phase 2, increased gapping occurred between percutaneous (17.8 mm [range 10.7-24.1, SD 6.4]) and open repairs (10.8 mm [range 7.6-14.9, SD 2.7, P = .037]). The ultimate load at failure was not statistically different between the 2 repairs.ConclusionsA percutaneous ATR repair technique using endoscopic assistance and absorbable suture demonstrated low complications and good outcomes in a cohort of patients, with high satisfaction, and excellent functional outcomes including high rates of return to sport. Cadaveric biomechanical testing demonstrated excellent survival during testing and minimal increase in gapping compared with open repair technique, representing sufficient strength to withstand forces seen in early rehabilitation. A percutaneous Achilles tendon repair technique with absorbable suture may minimize risks associated with operative repair while still maintaining the benefit of operative repair.Level of evidenceLevel IV, retrospective case series.
| S-EPMC8564947 | biostudies-literature
Project description:BackgroundFollowing percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our "traditional" or a "slowed down" rehabilitation after percutaneous surgical repair.MethodsSixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated.ResultsAt the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one.ConclusionFollowing percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study.Level of evidenceLevel II, prospective comparative study.
| S-EPMC8841642 | biostudies-literature
Project description:To date, there is no consensus concerning the treatment of acute Achilles tendon ruptures. Although surgical treatment decreases the risk of a recurrent rupture, it is not without complications. In particular, percutaneous sutures may cause a lesion of the sural nerve. The purpose of this Technical Note is to describe a reliable and reproducible surgical procedure for treating these lesions. The first operative phase consists of an ultrasound detection that makes it possible to identify the tendon extremities and the sural nerve, which is necessary to secure the posterolateral arthroscopic tract as well as to perform the percutaneous suture. The entry point is thus centered on the lesion and placed at a distance from any surrounding nerve risk. The second arthroscopic phase makes it possible to release the tendon lesion, control the transtendon passage of the surgical threads, and evaluate the dynamic contact of the tendon edges. At the end of the intervention, the complete disappearance from the transillumination via the rupture also makes it possible to ensure the disappearance of the tendon gap. Achilles tendon percutaneous sutures after the ultrasound detection and under arthroscopic control thus makes it possible to control the contact of the tendon edges, while at the same time decreasing the risk of a lesion of the sural nerve, with minimal scarring.
| S-EPMC6551569 | biostudies-literature
Project description:PurposePercutaneous repair is a good option for acute Achilles tendon rupture. Although it overcomes the complications of open technique, it carries the risk of sural nerve injury and inadequate repair. In this study, we explore if the use of intra-operative ultrasound with percutaneous technique has any advantageous effect on final results of repair.MethodsThis is a prospective randomized study done between May 2014 and December 2020. It included 91 patients with complete acute Achilles tendon rupture distributed in 2 groups with homogenous clinical and demographic data. Group A (n = 47) included those managed by percutaneous repair with assistant of an intra-operative ultrasound. Group B (n = 44) included those done without the assistant of ultrasound. Post-operative evaluation was done clinically by the American Orthopedic Foot and Ankle Society score, calf muscle circumference and single heel rise test and radiologically by Magnetic Resonance Image.ResultsPatients of both groups reported continuous improvement of the American Orthopedic Foot and Ankle Society score with time. However, patient of group A recorded better functional outcome score at 3 months postoperatively. We recorded longer operative time in group A than those in group B. Continuous improvement of maximum calf circumference was observed in both groups. Satisfactory healing was noticed to happen faster in patients of group A than those of group B. We recorded two cases of re-rupture and two cases of sural nerve injury in group B with no reported complication in group A.ConclusionThe use of an intra-operative ultrasound with percutaneous repair of acute rupture of Achilles tendon can improve the quality of repair as evidenced by quicker satisfactory healing and earlier regain of activity. Also, it can help in proper localization of sural nerve in relation to lateral edge of Achilles tendon.Trial registrationClinical Trials.gov Identifier: NCT04935281.
| S-EPMC9532319 | biostudies-literature
Project description: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. Technique Video Video 1 Detailed description of our preferred technique using ultrasound guidance during Achilles tendon repair with the Percutaneous Achilles Repair System (PARS) system. The ultrasound probe is placed over the posterior aspect of the ankle, overlying the Achilles tendon. The patient is in the prone position on the operating table. In the long axis view, the longitudinal fibers of the Achilles tendon and paratenon can be visualized. Moving distally, the Achilles tendon can be visualized as it inserts onto the calcaneus. Moving from distal to proximal, the Achilles tendon can be seen fanning out from a cord-like structure to more of a ribbon-like structure as it extends into the gastrocnemius and soleus. In the short-axis view, the “broom-end” appearance of the tendon can be appreciated. Moving lateral to the tendon, the sural vein and nerve can be visualized and avoided during the PARS repair. The sural nerve can be identified by its location and the classic honeycomb appearance, in contrast to the accompanying sural vein, which is hypoechoic in nature and compressible. While using the ultrasound intraoperatively, the surgeon can ensure the PARS needles are passed through the jig into the bulk of the Achilles tendon. This can be visualized on both the short- and long-axis views after each suture pass and can help decrease risk of suture cutout due to poor suture placement. Use of the ultrasound intraoperatively also allows the surgeon to identify the location of the sural nerve, and avoid it during the procedure and with each needle pass. After each needle pass is confirmed on ultrasound to have proper position, the remainder of the repair proceeds as normal.
| S-EPMC9984726 | biostudies-literature
Project description:In the treatment of acute Achilles tendon rupture, recent studies demonstrate that conservative treatment with functional rehabilitation provides good results, with nearly identical postoperative rerupture rates when compared with surgical treatment. Surgical treatment is indicated in patients with particular conditions, such as patients who are young active athletes who require early return to play or those who wish to avoid the muscle atrophy associated with conservative methods. If surgery is the selected option for treatment, the postoperative complications of each type of surgery must be considered. In conventional open repair, the most common complication is soft-tissue infection due to the high tension of soft tissue affected from the bowstring of the repaired tendon being kept in the equinus position of the ankle. For percutaneous methods, sural nerve entrapment and injury are the most commonly reported complications. Other methods, including endoscopy, require technical expertise as well as special equipment. Several types of combination approaches have been explored in the literature. We describe a combined open and percutaneous technique to repair the Achilles tendon, called the hybrid Achilles tendon repair. This technique has been developed to provide a simplified and reproducible method of hybrid repair in which the complications of previous methods are avoided and which can be done without special equipment.
| S-EPMC6019910 | biostudies-literature
Project description:The aim of this study is to introduce a self-designed, minimally invasive technique for repairing an acute Achilles tendon rupture percutaneously. Comparing with the traditional open repair, the new technique provides obvious advantages of minimized operation-related lesions, fewer wound complications as well as a higher healing rate. However, a percutaneous technique without direct vision may be criticized by its insufficient anastomosis of Achilles tendon and may also lead to the lengthening of the Achilles tendon and a reduction in the strength of the gastrocnemius. To address the potential problems, we have improved our technique using a percutaneous Kirschner wire leverage process before suturing, which can effectively recover the length of the Achilles tendon and ensure the broken ends are in tight contact. With this improvement in technique, we have great confidence that it will become the treatment of choice for acute Achilles tendon ruptures.
| S-EPMC6583741 | biostudies-literature
Project description:IntroductionVarious impairments such as soleus atrophy and consecutive functional deficits in end-range plantarflexion have been described in surgical repair of acute Achilles tendon rupture. The aim of this study was to assess the functional performance at midterm following open surgical repair.Materials and methodsThis cross-sectional study includes n = 52 patients which were tested on average 3.5 ± 1.4 years postoperatively using three different functional performance tests and patient-reported outcome measures. Two different surgical techniques (anatomical repair = AR vs. conventional repair = CR) were compared in a subanalysis. The testing included isokinetic strength testing, a novel setup of heel-rise testing using a marker-based 3D motion analysis system and a gait analysis.ResultsAt an average 3.5 years post-surgery, there is a persisting deficit in plantarflexion strength of 10.2%. Moreover, analysis of maximum peak torque angle and strength deficits according to the plantarflexion angle revealed that these deficits are not equally distributed across the range of motion. AR results in a significantly smaller deficit at 10° of plantarflexion compared to CR (13.9 vs. 29.9%, p < 0.05). This reflects into the functional performance during different modalities (static vs. dynamic) in this novel method of heel-rise testing.ConclusionIn summary, there are persisting functional deficits at > 3 years following Achilles tendon repair which range from strength deficits to specific impairments of functional performance e.g. during heel rise. Anatomical reconstruction is associated with an improved functional performance potentially due to a more symmetric strength during end-range plantarflexion which transfers into a higher satisfaction during athletic activities.Level of evidenceIII, retrospective cohort study.
| S-EPMC9217896 | biostudies-literature
Project description:The Achilles tendon is the largest and strongest tendon in the human body. It is the tendon that most often suffers injury and accounts for 20% of all tendon ruptures. These types of ruptures often occur 2 to 6 cm proximal to the stumps in an area of reduced vascularity. One such injury, the distal acute Achilles tendon rupture, is quite uncommon. For distal repairs, there have been studies that used a pullout technique, a button technique, and the use of local tendons for open-fashion augmentation. Although percutaneous repair and endoscopic flexor hallucis longus (FHL) tendon transfer techniques have been described for both acute midportion and chronic Achilles tendon rupture repair, there are no studies that describe the use of percutaneous sutures and biological augmentation with FHL transfer as a treatment option for acute distal injuries. The purpose of this Technical Note is to describe a novel approach to repair. It combines arthroscopic FHL tendon transfer with a percutaneous Achilles tendon repair technique for traumatic distal ruptures.
| S-EPMC8626620 | biostudies-literature