Patient-Reported Outcomes of Achilles Tendon Repair Using the Modified Gift-Box Technique With Nonabsorbable Suture Loop: A Consecutive Case Series

Background: We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides. Methods: A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses. Results: The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort. Conclusion: Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results. Level of Evidence: Level IV, retrospective case series.

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Electromyographic Evidence of Excessive Achilles Tendon Elongation During Isometric Contractions After Achilles Tendon Repair

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119883357 ◽

2019 ◽

Vol 7 (11) ◽

pp. 232596711988335

Author(s):

Malachy P. McHugh ◽

Karl F. Orishimo ◽

Ian J. Kremenic ◽

Julia Adelman ◽

Stephen J. Nicholas

Keyword(s):

Achilles Tendon ◽

Muscle Fiber ◽

Fourier Transforms ◽

Maximum Voluntary Contraction ◽

Tendon Repair ◽

Case Series ◽

Medial Gastrocnemius ◽

Level Of Evidence ◽

Achilles Tendon Repair ◽

Tendon Elongation

Background: Weakness in end-range plantarflexion has been demonstrated after Achilles tendon repair and may be because of excessive tendon elongation. The mean frequency (MNF) of surface electromyogram (EMG) data during isometric maximum voluntary contraction (MVC) increases with muscle fiber shortening. Hypothesis: During isometric plantarflexion, MNF during MVCs will be higher on the involved side compared with the uninvolved side after Achilles tendon repair because of excessive tendon elongation and greater muscle fiber shortening. Study Design: Case series; Level of evidence, 4. Methods: Isometric plantarflexion MVC torque was measured at 20° and 10° dorsiflexion, neutral, and 10° and 20° plantarflexion in 17 patients (15 men, 2 women; mean age, 39 ± 9 years) at a mean 43 ± 26 months after surgery. Surface EMG signals were recorded during strength tests. MNF was calculated from fast Fourier transforms of medial gastrocnemius (MG), lateral gastrocnemius (LG), and soleus (SOL) EMG signals. Results: Patients had marked weakness on the involved side versus the uninvolved side in 20° plantarflexion (deficit, 28% ± 18%; P < .001) but no significant weakness in 20° dorsiflexion (deficit, 8% ± 15%; P = .195). MNF increased when moving from dorsiflexion to plantarflexion ( P < .001), but overall, it was not different between the involved and uninvolved sides ( P = .195). However, differences in MNF between the involved and uninvolved sides were apparent in patients with marked weakness. At 10° plantarflexion, 8 of 17 patients had marked weakness (>20% deficit). MNF at 10° plantarflexion was significantly higher on the involved side versus the uninvolved side in patients with weakness, but this was not apparent in patients with no weakness (side by group, P = .012). Mean MNF at 10° plantarflexion across the 3 muscles was 13% higher on the involved side versus the uninvolved side in patients with weakness ( P = .012) versus 3% lower in patients with no weakness ( P = .522). Conclusion: Higher MNF on the involved side versus the uninvolved side in patients with significant plantarflexion weakness is consistent with greater muscle fiber shortening. This indicates that weakness was primarily because of excessive lengthening of the repaired Achilles tendon. If weakness was simply because of atrophy, a lower MNF would have been expected and patients would have had weakness throughout the range of motion. Surgical and rehabilitative strategies are needed to prevent excessive tendon elongation and weakness in end-range plantarflexion after Achilles repair.

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Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair

Foot & Ankle Orthopaedics ◽

10.1177/24730114211060063 ◽

2021 ◽

Vol 6 (4) ◽

pp. 247301142110600

Author(s):

Kristin C. Caolo ◽

Stephanie K. Eble ◽

Carson Rider ◽

Andrew J. Elliott ◽

Constantine A. Demetracopoulos ◽

...

Keyword(s):

Minimally Invasive ◽

Achilles Tendon ◽

Nerve Injury ◽

Sural Nerve ◽

Tendon Repair ◽

Suture Repair ◽

Complication Rates ◽

Achilles Tendon Repair ◽

Patient Reported ◽

Acute Rupture

Background: There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques. Methods: A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution’s registry. Demographics and complications were recorded. Results: PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection). Conclusion: Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences. Level of Evidence: Level III, retrospective cohort study.

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Granuloma formation secondary to Achilles tendon repair with nonabsorbable suture

International Journal of Surgery Case Reports ◽

10.1016/j.ijscr.2014.07.026 ◽

2014 ◽

Vol 5 (10) ◽

pp. 720-722 ◽

Cited By ~ 6

Author(s):

Adnan Kara ◽

Haluk Celik ◽

Ali Seker ◽

Mehmet Ali Uysal ◽

Metin Uzun ◽

...

Keyword(s):

Achilles Tendon ◽

Tendon Repair ◽

Granuloma Formation ◽

Nonabsorbable Suture ◽

Achilles Tendon Repair

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Achilles Tendon Repair Using Nonabsorbable Suture Loop for Modified Giftbox Technique

Techniques in Orthopaedics ◽

10.1097/bto.0000000000000050 ◽

2015 ◽

Vol 30 (1) ◽

pp. 33-38 ◽

Cited By ~ 1

Author(s):

Timothy L. Miller ◽

Jared L. Harwood ◽

Ryan K. Harrison ◽

Vincent S. Nerone

Keyword(s):

Achilles Tendon ◽

Tendon Repair ◽

Nonabsorbable Suture ◽

Achilles Tendon Repair

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Complications of Supine Surgical Achilles Tendon Repair

Foot & Ankle International ◽

10.1177/1071100718755474 ◽

2018 ◽

Vol 39 (6) ◽

pp. 720-724 ◽

Cited By ~ 4

Author(s):

John J. Marcel ◽

Katherine Sage ◽

Gregory P. Guyton

Keyword(s):

Achilles Tendon ◽

Supine Position ◽

Primary Repair ◽

Tendon Repair ◽

Case Series ◽

Neurologic Complication ◽

Complication Rates ◽

Achilles Tendon Repair ◽

Concomitant Surgery ◽

Tendon Surgery

Background: Open Achilles tendon surgery with the patient in the supine position potentially avoids the complications of the prone position, but the safety and viability of the supine position for this procedure are not known. The aim of this study was to test the hypothesis that supine positioning for open repair of acute Achilles tendon ruptures would be safe, with low wound and neurologic complication rates. Methods: Supine position safety in acute Achilles tendon repair was investigated. Consecutive cases of supine Achilles tendon surgical repair performed by one surgeon from 2010 to 2015 were retrospectively reviewed. Patients were included if they were surgically treated with primary repair in the supine position within 15 days of injury and did not undergo concomitant surgery. A paramedian incision 1 cm medial to the Achilles sheath was used. Initial chart review identified 161 patients who underwent any type of Achilles tendon surgery in the supine position, of whom 45 patients met the inclusion criteria. This group included 39 men and 6 women with an average age of 41 years (range, 20–66 years). Median length of follow-up was 116 days (range, 25–1,589 days). Average body mass index was 29 kg/m2 (range, 23–36 kg/m2). Results: There were no infections, sural nerve injuries, or reruptures. Conclusions: The supine position was safe for primary open Achilles tendon repair, with no wound or neurologic complications. Level of Evidence: Level IV, case series.

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Can Weakness in End-Range Plantar Flexion After Achilles Tendon Repair Be Prevented?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118774031 ◽

2018 ◽

Vol 6 (5) ◽

pp. 232596711877403 ◽

Cited By ~ 2

Author(s):

Karl F. Orishimo ◽

Sidse Schwartz-Balle ◽

Timothy F. Tyler ◽

Malachy P. McHugh ◽

Benjamin B. Bedford ◽

...

Keyword(s):

Achilles Tendon ◽

Plantar Flexion ◽

Tendon Repair ◽

Joint Stiffness ◽

Case Series ◽

Neutral Position ◽

Passive Stiffness ◽

Force Transmission ◽

Passive Joint ◽

Achilles Tendon Repair

Background: Disproportionate end-range plantar flexion weakness, decreased passive stiffness, and inability to perform a heel rise on a decline after Achilles tendon repair are thought to reflect increased tendon compliance or tendon lengthening. Since this was first noted, we have performed stronger repairs and avoided stretching into dorsiflexion for the first 12 weeks after surgery. Hypothesis: Using stronger repairs and avoiding stretching into dorsiflexion would eliminate end-range plantar flexion weakness and normalize passive stiffness. Study Design: Case series; Level of evidence, 4. Methods: Achilles repairs with epitendinous augmentation were performed on 18 patients. Plantar flexion torque, dorsiflexion range of motion (ROM), passive joint stiffness, and standing single-legged heel rise on a decline were assessed at 43 ± 24 months after surgery (range, 9 months to 8 years). Maximum isometric plantar flexion torque was measured at 20° and 10° of dorsiflexion, neutral position, and 10° and 20° of plantar flexion. Passive dorsiflexion ROM was measured with a goniometer. Passive joint stiffness was computed from the increase in passive torque from 10° to 20° of dorsiflexion. Tendon thickness was measured by use of digital calipers. Plantar flexion electromyographic (EMG) data were recorded during strength and functional tests. Analysis of variance and chi-square tests were used to assess weakness and function. Results: Marked weakness was evident on the involved side at 20° of plantar flexion (deficit, 26% ± 18%; P < .001), with no weakness at 20° of dorsiflexion (deficit, 6% ± 17%; P = .390). Dorsiflexion ROM was decreased 5.5° ± 8° ( P = .015), and tendon width was 8 ± 3 mm greater on the involved side ( P < .001). Passive joint stiffness was similar between the involved and noninvolved sides. Only 2 of 18 patients could perform a decline heel rise on the involved side compared with 18 of 18 on the noninvolved side ( P = .01). No difference in EMG amplitude was found between the involved and noninvolved sides during the strength or heel rise tests. Conclusion: The use of stronger repair techniques and attempts to limit tendon elongation by avoiding dorsiflexion stretching did not eliminate weakness in end-range plantar flexion. EMG data confirmed that end-range weakness was not due to neural inhibition. Physiological changes that alter the force transmission capability of the healing tendon may be responsible for this continued impairment. This weakness has implications for high-demand jumping and sprinting after Achilles tendon repair.

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Achilles Tendon Repair With Modified Giftbox Technique Using Nonabsorbable Suture Loops

Video Journal of Sports Medicine ◽

10.1177/2635025421992782 ◽

2021 ◽

Vol 1 (1) ◽

pp. 263502542199278

Author(s):

Timothy L. Miller ◽

Eric Welder

Keyword(s):

Achilles Tendon ◽

Tendon Repair ◽

Complication Rates ◽

Nonabsorbable Suture ◽

Achilles Tendon Repair ◽

Tendon Ruptures ◽

The Mean ◽

Mean Time ◽

Standard Techniques ◽

Mini Open

Background: Achilles tendon ruptures occur most commonly in male individuals aged between 30 and 60 years. Indications: Surgical options for treatment of acute midsubstance Achilles tendon ruptures in the athletically active population include open, mini-open, and percutaneous techniques. Surgical Technique: The giftbox suture configuration has been popularized by multiple authors. Here, a modified giftbox technique for Achilles tendon repair is shown in detail and uses nonabsorbable suture loops, a novel method for primarily repairing complete Achilles tendon ruptures. Results: This mini-open technique has demonstrated, at a minimum of 1-year follow-up, outcomes that are comparable with previously reported Achilles tendon repair procedures with no re-ruptures and low overall complication rates in the first 60 patients who have undergone this procedure. The mean time to release to unrestricted activity following repair by this technique is 24.3 weeks, which is earlier than most standard techniques. Conclusion: Achilles tendon repair using the modified gift box technique with nonabsorbable suture loops is a safe and reliable technique for repair of midsubstance tendon ruptures in athletically active patients. The mean time to release to unrestricted activity following repair by this technique is earlier than most standard techniques.

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