Percutaneous Achilles Tendon Repair Research Articles

Open and Percutaneous Approaches Have Similar Biomechanical Results for Primary Midsubstance Achilles Tendon Repair: A Meta-analysis

PurposeTo evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair. MethodsA systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, articles were required to be published in English, utilize a laboratory design using either human or animal tissue, and directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique versus percutaneous repair using either a locking or non-locking suture construct. The biomechanical outcomes evaluated were displacement (mm) and load to failure (N). ResultsTwelve studies met inclusion criteria, including 234 specimens (open: 97, percutaneous locking: 73; percutaneous non-locking: 64) that underwent primary mid-substance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (p=0.240) or load to failure (p=0.912) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (p=0.109) between the locking and non-locking tendon repair systems. ConclusionThe results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. Clinical RelevanceIn clinical studies, similar re-rupture rates have been observed after open or percutaneous Achilles tendon repair. It may be beneficial for surgeons to understand whether biomechanical differences exist between these repair techniques.

Ultrasound-guided Percutaneous Achilles Tendon Repair

There is no consensus as to the standard treatment of ruptured Achilles tendon. In this paper, we present an innovative method of treating Achilles tendon rupture. Ultrasound-guided percutaneous Achilles tendon repair is a minimally invasive method in the treatment of Achilles tendon rupture. This study aims to assess the feasibility and effectiveness of the procedure in treating ruptured Achilles tendons and in minimizing the complications of surgical percutaneous suturing. Thirty-four patients were treated for Achilles tendon rupture using a percutaneous suturing method under the control of ultrasound. The average follow-up was ~22 months with good and excellent results. As the sural nerve can be easily displayed by high-frequency real-time ultrasonography, the percutaneous repair of the Achilles tendon rupture can be aided by intraoperative ultrasound. The presented method is a quick and efficient surgery, which allows the treatment of torn Achilles tendons in a low-invasive way. The outcomes of this method are promising and enable the reduction of complications of the classic suturing methods. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical Comparison of Open vs Percutaneous Techniques for Primary Mid-Substance Achilles Tendon Repair: A Systematic Review and Meta-Analysis

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: Primary repair of mid-substance Achilles tendon rupture may be performed using an open or a percutaneous technique. Previous meta-analyses of clinical data comparing the two techniques have demonstrated mostly equivalent functional outcomes and re-rupture rates. Individual cadaveric studies have also compared the biomechanical properties of the two approaches. However, the results of these studies have been heterogeneous, and there is currently no consensus as to whether one technique may be biomechanically superior. The purpose of this meta-analysis was to evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair. Methods: A systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, articles were required to be published in English, utilized a cadaveric laboratory design, and had to directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique versus percutaneous repair using either the PARS (Arthrex) or Achillon (Integra) tendon repair systems. Evaluated outcomes included displacement (mm), load to failure (N), and stiffness (N/m). Results: Nine studies met inclusion criteria, including 190 cadaveric specimens (open: 83, PARS: 56; Achillon: 51) that underwent primary mid-substance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (p = 0.418; Figure 1), load to failure (p = 0.923; Figure 2), or stiffness (p = 0.195; Figure 3) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (p = 0.109; Figure 4) between the PARS and Achillon tendon repair systems. Conclusion: The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process for primary mid-substance Achilles tendon repair.

Poster 354: Biomechanical Comparison of Open versus Percutaneous Techniques for Primary Mid- Substance Achilles Tendon Repair: A Systematic Review and Meta-Analysis

Objectives: Primary repair of mid-substance Achilles tendon rupture may be performed using an open or a percutaneous technique. Previous meta-analyses of clinical data comparing the two techniques have demonstrated mostly equivalent functional outcomes and re-rupture rates. Individual cadaveric studies have also compared the biomechanical properties of the two approaches. However, the results of these studies have been heterogeneous, and there is currently no consensus as to whether one technique may be biomechanically superior. The purpose of this meta-analysis was to evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair. Methods: A systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, articles were required to be published in English, utilized a cadaveric laboratory design, and had to directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique versus percutaneous repair using either the PARS (Arthrex) or Achillon (Integra) tendon repair systems. Evaluated outcomes included displacement (mm), load to failure (N), and stiffness (N/m). Results: Nine studies met inclusion criteria, including 190 cadaveric specimens (open: 83, PARS: 56; Achillon: 51) that underwent primary mid-substance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (p = 0.418; Figure 1), load to failure (p = 0.923; Figure 2), or stiffness (p = 0.195; Figure 3) between the open and percutaneous techniques. Conclusions: The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process for primary mid-substance Achilles tendon repair.

Functional Outcome in Percutaneous Achilles Tendon Repair.

Rupture of the Achilles tendon is a considerable cause of morbidity with reduced function following injury. Randomized studies have so far failed to show a difference in outcome between operative and nonoperative management of Achilles tendon rupture, provided that no re-rupture occurs. Percutaneous Achilles repair has been suggested to result in superior patient satisfaction compared with open repair in patients with an acute Achilles tendon rupture. To assess and evaluate the functional outcome after percutaneous repair in patients of the acute and closed Achilles tendon ruptures. It was a prospective study conducted on patients diagnosed as having rupture of the Achilles tendon. A total of 25 patients with mean age of 44.4 (range 19-65) years were taken, who underwent percutaneous Achilles tendon repair. The number of patients who reported excellent or good scores (ATRS > 80) at 3, 6 and 12months were 0%, 16% and 100%, respectively. The mean AOFAS hind foot score at 3-, 6- and 12-month follow-ups was 77.9 ± 4.3, 92.04 ± 2.4 and 96.16.32 ± 1.1, respectively. The number of patients who reported excellent or good scores (AOFAS > 74) at 3, 6 and 12months were 76%, 100% and 100%, respectively. Most of the patients in our study showed no complications, and only 2 (8%) of patients had the features of sural nerve injury which was resolved in the subsequent follow-ups. Percutaneous repair of the Achilles tendon is an effective procedure which gives excellent functional outcome with very few complications. The percutaneous technique gives an additional advantage of less operative time, no wound complications, less damage to the soft tissues, and improved cosmesis as compared to the open repair.

Complications in repairing acute closed Achilles tendon rupture with micro-incision percutaneous Achilles tendon suture system

To analyze the causes, management and prevention of complications after micro-incision percutaneous repair of acute Achilles tendon rupture. A retrospective study indentyfied 279 patients with acute Achilles tendon rupture who underwent a mini-invasive procedure using the micro-incision percutaneous Achilles tendon suture system(MIPAS) from August 2008 to November 2019, including 269 males and 10 female;96 cases on the right side and 183 cases on the left side;aged from 18 to 64 years old with an average of (36.9±11.4 )years old. Surgery was performed 0.5 to 7 days with an average of(2.7±0.9 )days after injury. The incision-related complications, re-rupture, sural nerve injury, deep vein thrombosis, Achilles tendon adhesion, local pain, and ankle stiffness within 18 months after surgery were recorded, as well as the corresponding management and outcome, the causes and prevention measures were analyzed. No superficial or deep infection was found in all patients, symptomatic Achilles tendon adhesion and ankle stiffness were not observed, delayed suture foreign-body reactions occurred in 2 cases (0.7%), re-rupture in 5 cases (1.8%), sural nerve injury in 3 cases (1.1%), 21 cases(7.5%) with skin invagination at puncture site, 2 cases (0.7%) with symptomatic vein thrombosis, and 45 cases (16.1%) of transient posterior medial malleolus pain. After individualized treatment, the function was good. American Orthopeadic Foot & Ankle Sciety(AOFAS) score was 93 to 100 with an average of(98.9±5.4) scores. Despite the occurrence of unique complications with MIPAS, it shows low functionally-related complications rates, such as incision-related complications, re-rupture, sural nerve injury, deep vein thrombosis and ankle stiffness.

Open Achilles Tendon Repair.

An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury-and the resulting open repair-are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible. Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion. Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport1,2. Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair3. Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness)2. Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment. Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al.4, 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no reruptures. In a recent meta-analysis by Meulenkamp et al.5, the authors found that operative repair of Achilles tendon rupture was associated with a reduced risk of rerupture compared with primary immobilization (i.e., conventional cast immobilization with delayed weight-bearing for at least 6 weeks only). However, open surgical repair, minimally invasive repair, and functional rehabilitation all had similar risk of rerupture5. In a review by Ochen et al.6 that analyzed 29 studies with a total of 15,862 patients, operative repair was associated with a significantly lower risk of rerupture compared with nonoperative treatment (2.3% versus 3.9%, respectively). However, operative treatment was also associated with a significantly higher complication rate compared with nonoperative treatment (4.9% versus 1.6%, respectively)6. Finally, in a meta-analysis by Soroceanu et al.7, the authors found that if early range-of-motion protocols and functional rehabilitation were utilized, operative and nonoperative treatment resulted in similar outcomes and equivalent rates of rerupture. To prevent rerupture of an Achilles tendon, remind patients to engage in adequate stretching and warming prior to physical activity.Palpate and locate the tendon defect prior to making the first incision.Immobilize the ankle joint in a splint for 2 weeks postoperatively in maximum plantar flexion.Pitfalls include:○ Poor suture management leading to tangling in the repair.○ Undertensioning or overtensioning of the repair, which can be avoided by sterilely draping out both legs and checking resting tension intraoperatively.○ Failure to close the paratenon, causing scarring of the skin or surrounding tissues, which can be avoided by making a relieving incision on the deep surface of the paratenon.○ Leaving suture knots on the dorsal side of the repair that may aggravate the skin. MRI = magnetic resonance imagingESU = electrosurgical unit.

Reparación percutánea del tendón de Aquiles con sutura reabsorbible: resultados y complicaciones

ObjectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures. Material and methodsA prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted. Inclusion criteria≥18 years of age, non-insertional (2–8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected.Patients were assessed using visual analogue scale at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected. ConclusionsIn our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Artículo traducido] Reparación percutánea del tendón de Aquiles con sutura reabsorbible: resultados y complicaciones

Background and objectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures. Material and methodsProspective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019). Inclusion criteria≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected. ResultsVAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries). ConclusionsPercutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Percutaneous achilles tendon repair with absorbable suture: Outcomes and complications

ObjectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures. Material and methodsA prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted. Inclusion criteria≥18 years of age, non-insertional (2–8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected.Patients were assessed using visual analogue scale (VAS) at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score (ATRS) were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected. ConclusionsIn our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Utilizing A Percutaneous Versus Open Achilles Tendon Repair Technique for Treating Acute Achilles Tendon Ruptures in Physically Active Adults: A Critically Appraised Topic.

Acute Achilles tendon ruptures can be devastating injuries with the potential to significantly alter an individual's ability to perform functional activities. Given the rise in the incidence of acute Achilles tendon ruptures, it is important to determine whether percutaneous versus open Achilles tendon repair facilitates superior outcomes. In physically active adults with an acute Achilles tendon rupture, does performing percutaneous Achilles tendon repair result in improved outcomes compared with open Achilles tendon repair? Percutaneous Achilles tendon repair has similar efficacy as open Achilles tendon repair in facilitating return to activity/sport, and demonstrates improvement in short-term functional outcomes with potentially lower wound complication rates. Evidence supports the utilization of percutaneous Achilles tendon repair in physically active adult patients with acute Achilles tendon ruptures. It is important to critically review the benefits, risks, and alternatives of each treatment option based on patient characteristics. In addition, postoperative expectations should be discussed with the patient to set appropriate goals for recovery and improve overall satisfaction. A grade B recommendation can be made based on "fair" to "good" evidence from 2 level 2b studies and 1 Level 1b study to support the utilization of percutaneous Achilles tendon repair techniques.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

Background and objectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures. Material and methodsProspective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).Inclusion criteria: ≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography.Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected. ResultsVAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries). ConclusionsPercutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

No Difference in Return to Duty Between Minimally Invasive, Percutaneous Achilles Tendon Repair and Nonoperative Functional Rehabilitation in Active Duty Military Members

Category:Sports; Trauma; OtherIntroduction/Purpose:Achilles tendon ruptures are common injuries in the active duty US military population. Timely rehabilitation has critical importance in force readiness. There remains debate about optimal treatment of Achilles tendon ruptures. Recent studies have found decreased risk of rerupture but increased complication rates with operative management, with similar times to full recovery. The development of a minimally invasive, percutaneous Achilles tendon technique has shown lower rates of wound complications than open management, with similar re-rupture rates. However, there exists no comparative studies between the percutaneous, minimally invasive Achilles tendon surgery and nonoperative management. This was a retrospective cohort study comparing the results of the Percutaneous Achilles Repair System (PARS) and nonoperative management in the active duty military population.Methods:All Achilles tendon injuries in active duty patients were identified using the MHS system M2 from January 1, 2016 to December 31, 2020. Inclusion and exclusion criteria were applied and charts were reviewed. Demographic and treatment information were recorded. Time to return to duty, rerupture, complications, and deep vein thrombosis (DVT) were recorded and compared between each cohort. 47 patients met inclusion criteria with an average age of 38.7 years. There were 23 patients in the percutaneous operative group and 24 patients in the nonoperative group. Patients in the nonoperative group underwent regular functional rehabilitation supervised by a licensed physical therapist under the tri-service rehabilitation guidelines, based on the Willits protocol for nonoperative management (2010). 2 patients failed nonoperative management and underwent open Achilles reconstruction. They were excluded from the time to return to duty analysis. Demographics were described. There were no significant differences in group demographics.Results:There was no difference in time to return to duty in the nonoperative and percutaneous Achilles tendon repair (160.5 days, 5.35 months vs 161.7 days, 5.39 months) cohorts (p=0.47). No patient failed to return to duty due to treatment of an Achilles rupture. There were no DVTs in either group. There was 1 wound complication (infection) (4.3%) and 3 instances of postoperative paresthesias (2 sural, 1 peroneal) 13% in the operative cohort. 2 patients failed nonoperative management (reruptured Achilles tendon) and underwent open reconstruction with flexor halluces longus augmentation (8%). The operative cohort had a higher rate of complications (17.3% vs 8.3%, p=0.42, OR=2.11, CI= (0.34, 12.86)), although this was not statistically significant. There were no reruptures in the operative cohort.Conclusion:There was no difference in time to return to duty in the nonoperative and percutaneous Achilles tendon repairs. There was a higher rate of reruptures in the nonoperative group. Percutaneous operative treatment had a higher risk of complications. There were no failures in the operative cohort. The final decision on management of acute Achilles tendon ruptures should be based on specific patient factors and shared decision to return military members back to duty as quickly as possible. Prospective or well designed randomized controlled trials are necessary in the future to better delineate outcomes between nonoperative and percutaneous Achilles rupture management.

Minimally Invasive Mid-Substance Achilles Tendon Repair Using the Percutaneous Achilles Repair System (PARS).

Minimally Invasive Mid-Substance Achilles Tendon Repair Using the Percutaneous Achilles Repair System (PARS).

Retrospective Comparative Study between Open and Modified Ultrasound-guided Percutaneous Achilles Tendon Repair

Retrospective Comparative Study between Open and Modified Ultrasound-guided Percutaneous Achilles Tendon Repair

Arthroscopic Flexor Halluces Longus Transfer and Percutaneous Achilles Tendon Repair for Distal Traumatic Ruptures

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.

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture.

Background:Following 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.Methods:Sixty 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.Results:At 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.Conclusion:Following 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 Evidence:Level II, prospective comparative study.

Mini-Invasive, Ultrasound Guided Repair of the Achilles Tendon Rupture-A Pilot Study.

Percutaneous acute Achilles tendon rupture suturing has become a leading treatment option in recent years. A common complication after this mini-invasive procedure is sural nerve injury, which can reduce the patients’ satisfaction and final outcomes. High-resolution ultrasound is a reliable method for localizing the sural nerve, and it can be performed intra-operatively; however, the long-term results are yet unknown. The aim of the study was to retrospectively evaluate the long-term results of percutaneous Achilles tendon repair supported with real-time ultrasound imaging. We conducted 57 percutaneous sutures of acute Achilles tendon rupture between 2005 and 2015; 30 were sutured under sonographic guidance, while 27 were performed without sonographic assistance. The inclusion criteria were acute (less than 7 days) full tendon rupture, treatment with the percutaneous technique, age between 18 and 65 years, and a body mass index (BMI) below 35. The operative procedure was carried out by two surgeons, according to the surgical technique reported by Maffulli et al. In total, 35 patients were available for this retrospective assessment; 20 (16 men and 4 women) were treated with sonographic guidance, while 15 (12 men and 3 women) underwent the procedure without it. The mean follow-up was 8 years (range, 3–13 years). The sural nerve was localized 10 mm to 20 mm (mean, 15.8; SD, 3.02) laterally from the scar of the Achilles tendon tear. There was no significant difference between groups with respect to the FAOQ score (P < 0.05). High-resolution ultrasounds performed intra-operatively can minimize the risk of sural nerve injury during percutaneous Achilles tendon repair.

COMPARATIVE STUDY BETWEEN OPEN AND PERCUTANEOUS REPAIR FOR ACUTE ACHILLES TENDON RUPTURE

There is controversy between conservative and operative treatment of acute achilles tendon rupture. Operative treatment of achilles tendon rupture can be done through both percutaneous and open technique. Open repair of achilles tendon rupture was associated with higher incidence of wound complications while percutaneous repair was associated with higher incidence of tendonre-rupture rate and sural nerve injury. In this study, we aim to assess the functional outcomes of both open and percutaneous repair of acute achilles tendon rupture and the incidence of complications in both repair types. Twenty patients with acute achilles tendon rupture were retrospectively reviewed and evaluated. Ten patients were treated through percutaneous repair and ten patients were treated through open repair. The patients were followed up for at least one year and evaluated at the last follow up visit using Achilles Tendon Rupture Score (ATRS). Complications for each group were recorded. Twenty patients were included in our study. Ten patients were subjected to percutaneous repair and ten patients were subjected to open repair. There were two case of wound infection and one case of delayed skin healing in patients treated with open repair. The Achilles tendon Rupture Score (ATRS) yielded nearly similar results for both groups at the final follow up. There is no difference between open and percutaneous repair of achilles tendon rupture at a long-term follow up. Both groups had equal functional outcomes however the percutaneous repair of achilles tendon was associated with less wound complications than open repair

Clinical Outcomes and Cadaveric Biomechanical Analysis of Endoscopic Percutaneous Achilles Tendon Rupture Repair With Absorbable Suture.

Background:Percutaneous 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.Methods:A 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.Results:In 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.Conclusions:A 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 Evidence:Level IV, retrospective case series.