Histologic Evaluation of a 6-Month GraftJacket Matrix Biopsy Used for Achilles Tendon Augmentation

Background: Assessing implanted biological reinforcement graft success in soft-tissue repairs is typically limited to noninvasive measurements and functional outcome measures. However, there are times when a histologic snapshot of the graft incorporation may be possible owing to a nongraft-related postoperative complication, such as hardware failure. Methods: We histologically evaluated a 6-month biopsy sample from an Achilles tendon repair augmented with an acellular human dermal matrix (AHDM). A 57-year-old woman was treated for Haglund’s deformity of the Achilles tendon. The Achilles tendon was fixed to the calcaneus using a plate, and an AHDM was used to augment the primary repair of the tendon. At 6 months, the hardware was removed owing to prominence, and a biopsy of the AHDM was performed. The specimen was prepared and stained using hematoxylin and eosin, Verhoeff-van Gieson, Movat’s pentachrome, and toluidine blue stains. Results: Visually, the graft appeared normal and incorporated with the native tendon. No repeated tear was observed, and results of tests for infection were negative. Histologically, the graft was infiltrated predominantly with fibroblasts and demonstrated numerous blood vessels. Positive proteoglycan staining in the AHDM and at sites of vascularity indicated probable transformation to tendon-like tissue. Conclusions: These histologic findings suggest that the AHDM is highly biocompatible, supports revascularization and repopulation with noninflammatory host cells, and becomes incorporated by surrounding tendon tissue. (J Am Podiatr Med Assoc 99(2): 104–107, 2009)

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High-Volume and Privately Owned Ambulatory Surgical Centers Reduce Costs in Achilles Tendon Repair

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120912398 ◽

2020 ◽

Vol 8 (4) ◽

pp. 232596712091239

Author(s):

Lambert T. Li ◽

Carlin Chuck ◽

Steven L. Bokshan ◽

Ryan O’Donnell ◽

Raymond Y. Hsu ◽

...

Keyword(s):

Achilles Tendon ◽

Primary Repair ◽

Statistical Significance ◽

Univariate Analysis ◽

Tendon Repair ◽

Cost Savings ◽

High Volume ◽

Achilles Tendon Repair ◽

Ambulatory Surgical Centers ◽

Privately Owned

Background: While Achilles tendon repairs are common, little data exist characterizing the cost drivers of this surgery. Purpose: To examine cases of primary Achilles tendon repair, primary repair with graft, and secondary repair to find patient characteristics and surgical variables that significantly drive costs. Study Design: Economic and decision analysis; Level of evidence, 3. Methods: A total of 5955 repairs from 6 states were pulled from the 2014 State Ambulatory Surgery and Services Database under the Current Procedural Terminology codes 27650, 27652, and 27654. Cases were analyzed under univariate analysis to select the key variables driving cost. Variables deemed close to significance ( P < .10) were then examined under generalized linear models (GLMs) and evaluated for statistical significance ( P < .05). Results: The average cost was $14,951 for primary repair, $23,861 for primary repair with graft, and $20,115 for secondary repair ( P < .001). In the GLMs, high-volume ambulatory surgical centers (ASCs) showed a cost savings of $16,987 and $2854 in both the primary with graft and secondary repair groups, respectively (both P < .001). However, for primary repairs, high-volume ASCs had $2264 more in costs than low-volume ASCs ( P < .001). In addition, privately owned ASCs showed cost savings compared with hospital-owned ASCs for both primary Achilles repair ($2450; P < .001) and primary repair with graft ($11,072; P = .019). Time in the operating room was also a significant cost, with each minute adding $36 of cost in primary repair and $31 in secondary repair (both P < .001). Conclusion: Private ASCs are associated with lower costs for patients undergoing primary Achilles repair, both with and without a graft. Patients undergoing the more complex secondary and primary with graft Achilles repairs had lower costs in facilities with greater caseload.

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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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Ultrasonographic Evaluation of the Early Healing Process After Achilles Tendon Repair

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118789883 ◽

2018 ◽

Vol 6 (8) ◽

pp. 232596711878988 ◽

Cited By ~ 3

Author(s):

Kunihiko Hiramatsu ◽

Akira Tsujii ◽

Norimasa Nakamura ◽

Tomoki Mitsuoka

Keyword(s):

Achilles Tendon ◽

Primary Repair ◽

Healing Process ◽

Tendon Repair ◽

Case Series ◽

Return To Sports ◽

Level Of Evidence ◽

Unaffected Side ◽

The Mean ◽

Early Healing

Background: Little is known about early healing of repaired Achilles tendons on imaging, particularly up to 6 months postoperatively, when patients generally return to participation in sports. Purpose: To examine changes in repaired Achilles tendon healing with ultrasonography for up to 12 months after surgery. Study Design: Case series; Level of evidence, 4. Methods: Ultrasonographic images of 26 ruptured Achilles tendons were analyzed at 1, 2, 3, 4, 6, and 12 months after primary repair. The cross-sectional areas (CSAs) and intratendinous morphology of the repaired tendons were evaluated using the authors’ own grading system (tendon repair scores), which assessed the anechoic tendon defect area, intratendinous hyperechoic area, continuity of intratendinous fibrillar appearance, and paratendinous edema. Results: The mean ratios (%) of the CSA for the affected versus unaffected side of repaired Achilles tendons gradually increased postoperatively, reached a maximum (632%) at 6 months, and then decreased at 12 months. The mean tendon repair scores increased over time and reached a plateau at 6 months. Conclusion: Ultrasonography is useful to observe the intratendinous morphology of repaired Achilles tendons and to provide useful information for patients who wish to return to sports. Clinical parameters such as strength, functional performance, and quality of healed repaired tendons should also be assessed before allowing patients to return to sports.

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Use of a Non-Crosslinked Porcine Dermal Matrix in Repair of the Achilles and Other Tendons of the Foot

Foot & Ankle Specialist ◽

10.1177/1938640017751189 ◽

2018 ◽

Vol 11 (6) ◽

pp. 514-519 ◽

Cited By ~ 2

Author(s):

Ali A. Anaim

Keyword(s):

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Case Series ◽

Foot And Ankle ◽

Dermal Matrix ◽

Matrix Methods ◽

Biological Matrix ◽

Tissue Matrix

Background. Ankle tendon augmentation with biological matrixes has been shown to be beneficial, especially for Achilles tendon rupture as it adds to the integrity of the repair. Biologic matrix augmentation has been used increasingly in chronic and complex injuries where reinforcement is required. The objective of this study was to present outcomes of a series of patients who underwent tendon repair augmented with a new biologic matrix. Methods: Sixteen patients underwent ankle tendon repair, augmented with Proformix biologic tissue matrix. Patients were evaluated pre- and postoperatively for function and pain, and were followed for up to 3 years for complications. Results: This study included 10 females and 6 males, with a mean age of 44.6 years (range, 23-71 years). Patients were evaluated at 2 months postoperatively, and then further followed for a mean 19.0 months (range 7-38 months) to assess complications and reinjuries. Foot and Ankle Disability Index scores significantly increased from preoperatively (38.3) to 2 months postoperatively (85.2) ( P < .001). Furthermore, there were no reports of reruptures or significant complications. Conclusions: Weakness or rupture in tendons of the foot, especially the Achilles tendon, can be treated surgically and the repair augmented with Proformix, a new, biological matrix. Our study presented a series of 16 patients whose surgical repairs had been augmented with the new biological matrix, all of whom have achieved excellent results. Levels of Evidence: Level IV: Case series

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Biological incorporation of human acellular dermal matrix used in Achilles tendon repair

Cell and Tissue Banking ◽

10.1007/s10561-017-9628-3 ◽

2017 ◽

Vol 18 (3) ◽

pp. 403-411 ◽

Cited By ~ 7

Author(s):

Giampietro Bertasi ◽

Windy Cole ◽

Brian Samsell ◽

Xiaofei Qin ◽

Mark Moore

Keyword(s):

Achilles Tendon ◽

Tendon Repair ◽

Acellular Dermal Matrix ◽

Dermal Matrix ◽

Achilles Tendon Repair ◽

Acellular Dermal ◽

Human Acellular Dermal Matrix

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A Biomechanical Study of Achilles Tendon Repair Augmentation Using GraftJacket Matrix

Foot & Ankle International ◽

10.3113/fai.2008.0329 ◽

2008 ◽

Vol 29 (3) ◽

pp. 329-333 ◽

Cited By ~ 55

Author(s):

F. Alan Barber ◽

John E. McGarry ◽

Morley A. Herbert ◽

Robert Bentley Anderson

Keyword(s):

Achilles Tendon ◽

Primary Repair ◽

Tendon Repair ◽

Rehabilitation Program ◽

Biomechanical Study ◽

Matched Pair ◽

Control Group ◽

Achilles Tendon Repair ◽

Ultimate Failure ◽

Strength And Stiffness

Background: Ruptured Achilles tendons benefit from primary repair by decreasing re-rupture rates and allowing earlier range of motion. A stronger repair might allow for more aggressive rehabilitation decreasing postoperative stiffness, calf atrophy, and repair site gapping. The hypothesis of this study was that human dermal allograft augmentation of an Achilles repair would significantly increase repair strength and stiffness. This study evaluated strength and stiffness of an Achilles tendon repair augmented with a human dermal allograft (GraftJacket). Materials and Methods: Eight matched pairs of human cadaver legs were used. Simulated Achilles tendon ruptures were created 4 cm proximal to the calcaneal insertion. All tendons were repaired with a Krackow locking loop stitch. One of each matched pair was augmented with GraftJacket. Each construct was pre-loaded at 10 N and cyclically loaded (20 cycles) from 2 N to 30 N at a rate of 5 N/sec on an Instron machine. This was followed by testing to failure at a displacement rate of 6 mm/sec. Results: The ultimate failure load in the control group was 217 N ± 31 compared to 455 N ± 76.5 in the GraftJacket group ( p < 0.001). The mean stiffness in the control group was 4.3 ± 0.83 N/mm which was significantly less than the 12.99 ± 5.34 N/mm in the GraftJacket group ( p = 0.002). Conclusion: The augmentation of an Achilles tendon repair with GraftJacket significantly increased repair strength and stiffness. Clinical Significance: These findings suggest that a GraftJacket augmented Achilles tendon repair could acutely withstand a more aggressive rehabilitation program, potentially decreasing ankle stiffness and allowing earlier return to full activities.

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