Suture-Only Repair Versus Suture Anchor–Augmented Repair for Achilles Tendon Ruptures With a Short Distal Stump

Background: Chronic noninsertional Achilles tendinosis can result in an acute Achilles tendon rupture with a short distal stump. In such tendon ruptures, there is a limited amount of adequate tissue that can hold suture, thus presenting a challenge for surgeons who elect to treat the rupture operatively. Hypothesis: Adding suture anchors to the repair construct may result in biomechanically stronger repairs compared with a suture-only technique. Study Design: Controlled laboratory study. Methods: Nine paired Achilles-calcaneus complexes were harvested from cadavers. An artificial Achilles rupture was created 2 cm proximal to the insertion on the calcaneus. One specimen from each cadaver was assigned to a suture-only or a suture anchor–augmented repair. The contralateral specimen of the same cadaver received the opposing repair. Cyclic testing was then performed at 10 to 100 N for 2000 cycles, and load-to-failure testing was performed at 0.2 mm/s. This was followed by analysis of repair displacement, gapping at repair site, peak load to failure, and failure mode. Results: The suture anchor–augmented repair exhibited a 116% lower displacement compared with the suture-only repair (mean ± SD, 1.54 ± 1.13 vs 3.33 ± 1.47 mm, respectively; P < .03). The suture anchor–augmented repair also exhibited a 45% greater load to failure compared with the suture-only repair (303.50 ± 102.81 vs 209.09 ± 48.12 N, respectively; P < .04). Conclusion: Suture anchor–augmented repairs performed on acute Achilles tendon ruptures with a short distal stump are biomechanically stronger than suture-only repairs. Clinical Relevance: Our results support the use of suture anchor–augmented repairs for a biomechanically stronger construct in Achilles tendon ruptures with a short distal stump. Biomechanically stronger repairs may lead to less tendon repair gapping and failure, increasing the ability to start early active rehabilitation protocols and thus improving patient outcomes.

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Management of Missed Traumatic Achilles Tendon Rupture in a Pediatric Patient: A Case Report

Pediatric Traumatology Orthopaedics and Reconstructive Surgery ◽

10.17816/ptors77113 ◽

2021 ◽

Vol 9 (4) ◽

pp. 465-470

Author(s):

Saad Andaloussi

Keyword(s):

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Skin Wound ◽

Plantaris Tendon ◽

First Case ◽

Tendon Ruptures ◽

Post Traumatic

BACKGROUND: Missed traumatic Achilles tendon ruptures in children are rarely reported in the literature. Various techniques have been described to reconstruct delayed Achilles tendon ruptures for adults, but the long-term consequences in the growing child are unknown. CLINICAL CASE: The article presents a clinical observation of a 8-year-old girl with missed rupture of the Achilles tendon operated 7 weeks after the trauma by end-to-end Kessler-type sutures augmented with the plantaris tendon. At 2-year follow-up, the patient was completely asymptomatic. DISCUSSION: A review of the literature shows that this is the third neglected pediatric case of post-traumatic Achilles tendon rupture. The first case concerns a 10-year-old boy treated successfully six weeks after the traumat by open surgical repair using the Bunnell sutures technique. The second patient was a 7-year-old girl, she was operated 8 weeks after the trauma with a termino-terminal tenorrhaphy using the Bunnell technique augmented with the plantaris tendon. CONCLUSIONS: Using the plantaris tendon to reinforce the Achilles tendon repair offers satisfactory results with minimal morbidity. Prognosis depends on the extent of tendon defect which determines the long-term functional outcome. Any skin wound that sits on the back of the leg requires a systematic and careful physical examination to check the integrity of the Achilles tendon.

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Functional Outcomes and MRI Results Following Knotless Repair of Acute Achilles Tendon Ruptures

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00459 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0045

Author(s):

Brian D. Steginsky ◽

Mallory Suhling ◽

Eric Giza ◽

Christopher D. Kreulen ◽

B. Dale Sharpe ◽

...

Keyword(s):

Surgical Technique ◽

Achilles Tendon ◽

Functional Outcomes ◽

Tendon Repair ◽

Surgical Techniques ◽

Wound Complications ◽

Distal Stump ◽

Achilles Tendon Repair ◽

Tendon Ruptures

Category: Ankle; Sports Introduction/Purpose: The surgical techniques for primary repair of acute Achilles tendon ruptures have evolved from large open incisions to mini-open and percutaneous techniques. Studies have demonstrated that lesser invasive surgical techniques may reduce the risk of post-operative wound complications. Knotless surgical repair of acute Achilles tendon ruptures can be performed through a mini-incision, but still permits a robust re-approximation of the tendon stumps and decreases suture burden through distal anchor fixation in the calcaneus. However, stress shielding and subsequent tendinosis of the distal tendon stump is a theoretical concern with this surgical technique. We hypothesize that our surgical technique allows for a durable repair through a minimally invasive approach, permitting a safe and accelerated rehabilitation protocol, excellent functional outcomes, and absence of distal stump tendinosis. Methods: A multicenter retrospective chart review was performed to identify all patients that underwent primary Achilles tendon repair using a knotless surgical technique with a minimum of one-year follow-up from three orthopedic foot and ankle surgeons’ practices. Exclusion criteria included: age <18, chronic Achilles tendon ruptures (>4 weeks), insertional Achilles tendon ruptures, revision Achilles surgery, peripheral neuropathy, and systemic inflammatory disease. All patients were contacted by phone and asked to return to the office for an MRI, clinical examination, and completion of functional outcome questionnaires. The primary outcome measure was the validated Achilles Tendon Total Rupture Score (ATRS). Secondary outcomes included the Visual Analog Score (VAS), postoperative complications, ankle range of motion, calf circumference, and single-heel rise. MRI was used to assess tendon continuity and healing, tendinosis, muscle atrophy, and bone marrow edema/stress fracture associated with anchor fixation in the calcaneus. MRI interpretation was performed by a single, blinded musculoskeletal radiologist. Results: Forty-three patients were identified with acute Achilles tendon ruptures. There were 36 patients (36/43, 84%) who underwent knotless Achilles tendon repair and agreed to participate in the study. The average time to clinical follow-up was 23.5 months (SD±16.3). The mean postoperative ATRS was 84.6 (SD±19.7). There was no significant difference in calf circumference (p=0.22), dorsiflexion (p=0.07), and plantarflexion (p=0.11) between the unaffected and surgical extremity at latest follow-up. One patient (1/36, 2.8%) experienced a re-rupture. There were no wound complications or neuritis. MRI was obtained in 26 patients (26/36, 72.2%) at an average of 17.5 months (SD±10.1). There were no MRI findings of distal stump tendinosis or calcaneal stress fractures. Thirty-two patients (32/36, 88.8%) returned to the same athletic activities one-year after surgery. Conclusion: There is paucity in the literature on functional outcomes following knotless Achilles tendon repair. In this multicenter study, we found that validated functional outcome scores and return to activity were similar to historical controls, with a low rate of surgical complications. MRI obtained in twenty-six patients (72.2%) at 17.5 months demonstrated an intact tendon without distal tendon stump stress shielding or calcaneal stress fracture. The knotless Achilles tendon repair is a unique surgical technique, minimizing suture burden and postoperative complications, while offering excellent functional outcomes and return to activity at two-year follow-up. The excellent clinical outcomes are corroborated by MRI.

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A Biomechanical Comparison of Limited Open Versus Krackow Repair for Achilles Tendon Rupture

Foot & Ankle Orthopaedics ◽

10.1177/2473011417715431 ◽

2017 ◽

Vol 2 (4) ◽

pp. 247301141771543 ◽

Cited By ~ 3

Author(s):

Robert G. Dekker ◽

Charles Qin ◽

Cort Lawton ◽

Muturi G. Muriuki ◽

Robert M. Havey ◽

...

Keyword(s):

Soft Tissue ◽

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Lower Limbs ◽

Gap Formation ◽

Postoperative Rehabilitation ◽

Significant Difference ◽

Load To Failure

Background: Soft tissue complications after Achilles tendon repair has led to increased interest in less invasive techniques. Various limited open techniques have gained popularity as an alternative to open operative repair. The purpose of this study was to biomechanically compare an open Krackow and limited open repair for Achilles tendon rupture. We hypothesized that there would be no statistical difference in load to failure, work to failure, and initial linear stiffness. Methods: A simulated Achilles tendon rupture was created 4 cm proximal to its insertion in 18 fresh-frozen cadaveric below-knee lower limbs. Specimens were randomized to open or limited open PARS Achilles Jig System repair. Repairs were loaded to failure at a rate of 25.4 mm/s to reflect loading during normal ankle range of motion. Load to failure, work to failure, and initial linear stiffness were compared between the 2 repair types. Results: The average load to failure (353.8 ± 88.8 N vs 313.3 ± 99.9 N; P = .38) and work to failure (6.4 ± 2.3 J vs 6.3 ± 3.5 J; P = .904) were not statistically different for Krackow and PARS repair, respectively. Mean initial linear stiffness of the Krackow repair (17.8 ± 5.4 N/mm) was significantly greater than PARS repair (11.8 ± 2.5 N/mm) ( P = .011). Conclusion: No significant difference in repair strength was seen, but higher initial linear stiffness for Krackow repair suggests superior resistance to gap formation, which may occur during postoperative rehabilitation. With equal repair strength, but less soft tissue devitalization, the PARS may be a favorable option for patients with risk factors for soft tissue complications.

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Retrospective Analysis of Mini-Open Repair Versus Open Repair for Acute Achilles Tendon Ruptures

Foot & Ankle Specialist ◽

10.1177/1938640012463052 ◽

2012 ◽

Vol 6 (1) ◽

pp. 15-20 ◽

Cited By ~ 9

Author(s):

Erin E. Klein ◽

Lowell Weil ◽

Jeffrey R. Baker ◽

Lowell Scott Weil ◽

Wenjay Sung ◽

...

Keyword(s):

Achilles Tendon ◽

Open Repair ◽

Surgical Intervention ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Level Of Evidence ◽

Tendon Ruptures ◽

Return To Activity ◽

Mini Open

Purpose: Debate exists over optimal treatment for acute Achilles tendon ruptures. Recent literature suggests the mini-open technique may provide the reliability of the open repair with the decreased complication rate of non-operative treatment. This retrospective review compares acute tendon ruptures treated with one of two techniques: open repair (TO) or mini-open repair (MOA). Methods & Results: Records were reviewed and 34 patients were found to meet the inclusion criteria for open or mini-open repair of an acute Achilles tendon rupture with follow up of at least 12 months. TO (n=16) and MOA (n=18) had no statistically significant differences in age at time of injury [TO: 41 + 2.5 years (range 20 – 68); MOA: 46 + 2.5 years (range 33 – 73)] or time between injury and surgical repair [TO: 15 + 2 days (range 2 – 30); MOA: 15 + 2 days (range 2 – 30)]. Post-operative VISA-A scores were 82 + 10 (range 42 – 98) and 92 + 5 (range 66 – 100) for TO and MOA, respectively. Significant differences were found in the time between surgical intervention and beginning of rehabilitation [TO: Post op day 37 + 5 (range 21 – 46); MOA: Post op day 19 + 2 (range 7 – 32)] and the time between surgical intervention and full return to activity [TO: Post op month 7 + 1 (range 4 – 11); MOA: Post op month 5 + 0.6 (range 4 – 11)]. Conclusion: These results suggest that the mini-open repair provides acceptable surgical outcomes while optimizing patient function after Achilles tendon repair. Level of Evidence: Therapeutic, Level III: Retrospective Comparative

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Repair of Chronic Achilles Ruptures Has a High Incidence of Venous Thromboembolism

Foot & Ankle Specialist ◽

10.1177/1938640016679706 ◽

2016 ◽

Vol 10 (5) ◽

pp. 415-420 ◽

Cited By ~ 9

Author(s):

Mark J. Bullock ◽

William T. DeCarbo ◽

Mark H. Hofbauer ◽

Joshua D. Thun

Keyword(s):

Venous Thromboembolism ◽

Achilles Tendon ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Achilles Tendinopathy ◽

Flexor Hallucis Longus ◽

Achilles Tendon Repair ◽

Elective Repair ◽

High Incidence ◽

Tendon Ruptures

Background. Despite the low incidence of deep vein thrombosis (DVT) in foot and ankle surgery, some authors report a high incidence of symptomatic DVT following Achilles tendon rupture. The purpose of this study was to identify DVT risk factors inherent to Achilles tendon repair to determine which patients may benefit from prophylaxis. Methods. One hundred and thirteen patient charts were reviewed following elective and nonelective Achilles tendon repair. For elective repair of insertional or noninsertional Achilles tendinopathy, parameters examined included lateral versus prone positioning and the presence versus absence of a flexor hallucis longus transfer. For nonelective repair, acute Achilles tendon ruptures were compared to chronic Achilles tendon ruptures. Results. Of 113 Achilles tendon repairs, 3 venous thromboembolism (VTE) events (2.65%) occurred including 2 pulmonary emboli (1.77%). Seventeen of these repairs were chronic Achilles tendon ruptures, and all 3 VTE events (17.6%) occurred within this subgroup. Elevated body mass index was associated with VTE in patients with chronic Achilles ruptures although this did not reach significance ( P = .064). No VTE events were reported after repair of 28 acute tendon ruptures or after 68 elective repairs of tendinopathy. Two patients with misdiagnosed partial Achilles tendon tears were excluded because they experienced a VTE event 3 weeks and 5 weeks after injury, prior to surgery. Conclusion. In our retrospective review, chronic Achilles ruptures had a statistically significant higher incidence of VTE compared with acute Achilles ruptures ( P = .048) or elective repair ( P = .0069). Pharmaceutical anticoagulation may be considered for repair of chronic ruptures. Repair of acute ruptures and elective repair may not warrant routine prophylaxis due to a lower incidence of VTE. Levels of Evidence: Prognostic, Level III: Case Control Study

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A Biomechanical Comparison of a Limited Open and Standard Open Technique for Achilles Tendon Rupture Repair

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000156 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

Robert Dekker ◽

Charles Qin ◽

Cort Lawton ◽

Muturi Muriuki ◽

Robert Havey ◽

...

Keyword(s):

Soft Tissue ◽

Achilles Tendon ◽

Open Repair ◽

Achilles Tendon Rupture ◽

Testing Machine ◽

Tendon Repair ◽

Lower Limbs ◽

Gap Formation ◽

Load To Failure ◽

Biomechanical Comparison

Category: Basic Sciences/Biologics, Sports Introduction/Purpose: The drive to reduce soft tissue complications after Achilles tendon repair has led to increased interest in less invasive techniques. The PARS Achilles Jig System is one option that has gained popularity as an alternative to open repair. For many surgeons, standard open repair consists of a Krackow locking-loop technique. We compared the load to failure of a limited open and open Krackow technique for repair of Achilles tendon ruptures. Methods: Nine pairs of human cadaver lower limbs were randomized to undergo either a Krackow locking loop repair with epitendinous weave or a PARS Achilles Jig System Repair. Specimen were loaded to failure on a servo-hydraulic material testing machine. From load- displacement curves, initial linear stiffness, load to failure, and work to failure were calculated. Results: The average load to failure for Krackow repair (353.8 ± 88.8 N) and PARS repair (313.3 ± 99.9 N) was not statistically different (p = .38). The average work to failure for open repair (6.4 ± 2.3 J) and PARS repair (6.3 ± 3.5 J) was also not statistically different (p = .904). Mean initial linear stiffness of the Krackow repair (17.8 ± 5.4 N/mm) was significantly greater than the PARS repair (11.8 ± 2.5 N/mm) (p = .011). The predominant location of failure for Krackow repair was at the suture itself. In contrast, the PARS repair predominantly failed at the suture-tendon interface. Conclusion: The results suggest no difference between the Krackow and PARS repairs in terms of ultimate strength or work to failure. The Krackow repair demonstrated a higher initial linear stiffness than the PARS, which may imply a greater ability to withstand gap formation. With less devitalization to surrounding soft tissue and equal repair strength, the PARS system should be considered a favourable option for repair of ruptured Achilles tendons.

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Outcomes of Plantaris Tendon Augmentation in Acute Achilles Tendon Rupture Repair

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00409 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0040

Author(s):

Ryan G. Rogero ◽

Daniel Corr ◽

Andrew Fisher ◽

Joseph T. O’Neil ◽

Daniel J. Fuchs ◽

...

Keyword(s):

Achilles Tendon ◽

Functional Outcomes ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Complication Rates ◽

Plantaris Tendon ◽

Achilles Tendon Repair ◽

Patient Variables ◽

Tendon Ruptures

Category: Trauma; Ankle; Hindfoot; Sports Introduction/Purpose: Given the lack of consensus regarding the optimal surgical treatment for acute Achilles tendon ruptures, identifying techniques to maximize functional outcomes is crucial. Augmentation of Achilles tendon repair with the plantaris tendon is an established surgical technique that is thought to improve outcomes by reinforcing the repair site as well as decreasing soft tissue adhesions, though no studies have specifically looked at outcomes of its use. The purpose of this study is to compare the outcomes of acute Achilles tendon repairs managed with and without plantaris tendon augmentation. Methods: A retrospective review of patients undergoing open repair of acute Achilles tendon ruptures with a single fellowship- trained foot & ankle surgeon from 2010-2016 was performed. Patients <18 years of age, those whose procedures were >21 days from the date of injury, or whose repair was augmented with a flexor hallucis longus (FHL) tendon transfer or V-Y advancement were excluded. Operative report review determined if repair included plantaris augmentation. Augmentation involved weaving the tendon through the Achilles above and below the rupture site creating a box type biologic augmentation. Patients were contacted at >=2 years postoperatively to complete the Foot & Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and -Sports subscales, visual analog scale (VAS) for pain, as well as surveyed regarding their satisfaction with the surgical outcome using a 5- point Likert scale. Mann-Whitney U, Chi-squared and Fisher’s exact tests were performed to compare patient variables and postoperative outcomes. Results: One hundred twenty-eight patients undergoing repair of an acute Achilles tendon rupture were included, including 59 (46.1%) with plantaris tendon augmentation and 69 (53.9%) without. The two patient cohorts did not differ in any preoperative patient variables (p>0.0892). Patients with and without plantaris augmentation did not experience any significant difference in the rate of postoperative complications (p=1.000), including a 0% re-rupture rate in each group. Additionally, at an average follow-up of 57.1 months, the groups did not differ in FAAM-ADL score (p=0.7116), FAAM-Sports score (p=0.4024), the Single Assessment Numeric Evaluation (SANE) as part of the FAAM-Sports subscale (p=0.2572), VAS pain (p=0.1885), or outcome satisfaction (p=0.7317). Conclusion: Our study demonstrates that plantaris tendon augmentation does not improve patient functional outcomes following acute Achilles tendon repair, but also is not associated with increased complication rates. Further studies, including either higher-level prospective, randomized clinical studies or biomechanical evaluation of the technique, are indicated to justify this adjunctive procedure. [Table: see text]

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Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results As Compared With Acute Repair

The American Journal of Sports Medicine ◽

10.1177/0363546520908592 ◽

2020 ◽

Vol 48 (5) ◽

pp. 1181-1188 ◽

Cited By ~ 3

Author(s):

Nicola Maffulli ◽

Alessio D’Addona ◽

Gayle D. Maffulli ◽

Nikolaos Gougoulias ◽

Francesco Oliva

Keyword(s):

Minimally Invasive ◽

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Invasive Technique ◽

Suture Repair ◽

Distal Stump ◽

Percutaneous Repair ◽

Tendon Ruptures ◽

Repair Group

Background: Minimally invasive repair of acute Achilles tendon ruptures has been performed for several years, resulting in reduced morbidity as compared with open repair. Hypothesis: A minimally invasive technique can be used to manage Achilles tendon ruptures in patients presenting between 14 and 30 days from injury. Study Design: Cohort study; Level of evidence, 3. Methods: We prospectively recruited 21 consecutive patients who presented between 14 and 30 days after the index injury, and we compared them with 21 patients who were matched according to sex, age (±2 years), and level of activity, who presented within 14 days of the index injury. All patients underwent the same minimally invasive procedure under local anesthesia: a core suture repair consisting of a modified Bunnell suture in the proximal stump and a modified Kessler suture in the distal stump. Results: At 12 months after minimally invasive repair, patients with delayed treatment had a median Achilles tendon rupture score of 91 (SD, 2.4; range, 87-96) as compared with 91 (SD, 2.2; range, 86-96) in patients treated acutely, who presented at a median 2.4 days (range 1-6 days) from the injury. There were no significant differences between groups in terms of mean (SD) Achilles tendon resting angle: delayed repair group, −3.9° (2.0); acute repair group, −3.7° (1.9) ( P = .69). No patient in either group developed a wound infection. One patient in the acute group experienced an iatrogenic sural nerve injury. Conclusion: Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patient treated <14 after injury.

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Proximal and Distal Failure Site Analysis in Percutaneous Achilles Tendon Rupture Repair

Foot & Ankle International ◽

10.1177/1071100719867937 ◽

2019 ◽

Vol 40 (12) ◽

pp. 1424-1429 ◽

Cited By ~ 2

Author(s):

Pablo Wagner ◽

Emilio Wagner ◽

Mario López ◽

Gastón Etchevers ◽

Oscar Valencia ◽

...

Keyword(s):

Cyclic Loading ◽

Achilles Tendon ◽

Tendon Rupture ◽

Failure Load ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Cyclic Testing ◽

Load To Failure ◽

Fresh Frozen ◽

Distal Fixation

Background: Different techniques have been described for percutaneous Achilles tendon rupture repair, but no biomechanical evaluation has been performed separately for proximal and distal suturing techniques. The purpose of this study was to biomechanically analyze proximal versus distal percutaneous Achilles suture configurations during cyclic loading and load to failure. Methods: A simulated, midsubstance rupture was created 6 cm proximal to the calcaneal insertion in fresh-frozen cadaveric Achilles tendons. Fifteen proximal specimens were divided into 3 groups: (A1) triple locking technique, (A2) Bunnell-type technique, and (A3) double Bunnell-type technique. Twelve distal specimens were divided into 2 groups: (B1) triple nonlocking technique and (B2) oblique technique. Repairs were subjected to cyclic testing and load to failure. Load to failure, cause of failure, and tendon elongation were evaluated. Results: None of the proximal specimens and 7/12 of the distal ones failed in cyclic testing. The proximal fixation groups demonstrated significantly more strength than the distal groups ( P = .001), achieving up to 710 N of failure load in Group A3. Groups B1and B2 failed on average at 380 N with no difference between them ( P > .05). The majority of all repairs failed in the suture-tendon interface. Distal groups had more elongation during cyclic testing (13.7 mm) than proximal groups (9.4 mm) ( P = .02). Conclusion: The distal fixation site in this Achilles tendon repair was significantly weaker than the proximal fixation site. A proximal modified suture configuration increased resistance to cyclic loading and load to failure significantly. Clinical Relevance: A modification can be suggested to improve strength of the Achilles repair.

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Proximal and Distal Failure Site Analysis in Percutaneous Achilles Tendon Rupture Repair

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00432 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0043

Author(s):

Pablo Wagner ◽

Emilio Wagner ◽

Mario Lopez ◽

Gaston Etchevers ◽

Oscar Valencia ◽

...

Keyword(s):

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Cyclic Testing ◽

Suturing Technique ◽

Load To Failure ◽

Fresh Frozen ◽

Cause Of Failure ◽

Distal Fixation

Category: Ankle Introduction/Purpose: Different techniques have been described for Achilles Tendon Rupture repair, but no biomechanical evaluation have been performed separately for proximal and distal suturing techniques.The purpose of this study was to biomechanically analyze 3 proximal and 2 distal suture configurations during a simulated cyclic load and load to failure. It was hypothesized that proximal suturing technique was stronger than the distal one and that the modified double suturing technique was the strongest of all techniques. Methods: A simulated, mid-substance rupture was created 6 cm proximal to the calcaneal insertion in 15 fresh-frozen cadaveric Achilles tendons, obtaining 15 proximal and 12 distal samples. Specimens were tested independently and randomly allocated to different suture techniques: proximal fixation site groups: (A1) classic Dresden technique, (A2) modified Dresden, (A3) double modified Dresden; distal fixation groups: (B1) classic distal suture and (B2) modified distal suture. Repairs were subjected to a cyclic testing (1000 cycles of 50-200 N) and load to failure. Load to failure, cause of failure and tendon elongation was evaluated. Fischer’s test was used as statistical analysis. Results: None of the proximal tendon and 7/12 of the distal samples failed in cyclic testing. The proximal fixation groups demonstrated significantly more strength than the distal groups (p< 0.05) with average failure loads of 598 N, 587 N and 710 N for groups A1, A2 and A3 respectively (A3 stronger than A1 and A2, p=0,035). Groups B1 and B2 failed on average at 416 N and 351 N respectively, p=0.24. The majority of all repairs failed in the suture- tendon interphase.Regarding elongation, no significant differences were found between groups (p=0.57). Conclusion: The distal fixation site in the Dresden percutaneous Achilles tendon repair is weaker than the proximal fixation site. A proximal modified suture configuration increased resistance to cyclic loading and load to failure significantly. A modification in the proximal and distal fixation sites can be suggested to improve repair strength and hopefully achieve a better outcome.

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