Primary Achilles Tendon Repair Research Articles

Long-term results and complication following Achilles tendon rupture repair

Introduction Currently,there is no consensus regarding optimal treatment options of Achilles tendon rupture. The purpose of this study was to evaluate long term results of Achilles tendon repair using different surgical techniques, assess complication rate and subjective satisfactionMethods The study included patients treated for Achilles tendon rupture using minimally invasive and open surgical repair. Complications including re-rupture, infection, deep vein thrombosis and neuropraxia were identified. In order to evaluate the factors influencing the risk of postoperative complications, logistic regression analysis was performed. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) evaluated subjective outcomes.Results 130 patients with Achilles tendon tear were enrolled (123 primary and 7 revision cases). In primary repairs percutaneous technique was used in 60 % of cases (74/123), mini open technique – in 16 % (19/123), and open technique – in 24 % (30/123). Re-rupture occurred in 2.4 % of patients treated with minimally invasive techniques. There were no repeated ruptures following open repairs. Predominant number of infections was registered after open repairs and made 10 %, while minimally invasive techniques had 3.2 % of infections. Logistic regression analyses showed that steroid injection, open repair, application of tapes and autografts increased the risk of infectious complications. There were no significant differences in ATRS and AOFAS scores between different primary Achilles tendon repair techniques (p > 0.05).Discussion Results, obtained in the current study, are consistent with previously published data.Conclusions Open Achilles tendon repair showed a higher rate of infections, and lower rate of re-ruptures. The anamnesis of steroid injection, open repair, application of tapes and autografts increases the risk of infectious complications.

Conservative treatment outcome for Achilles tendon re-rupture occurring in the subacute phase after primary repair.

Until now, a treatment protocol for Achilles tendon re-rupture (ATRR) occurring in the postoperative period 5-12weeks following primary Achilles tendon repair has not been established. We refer to this time frame as the subacute postoperative phase, and the objective of this study was to assess the efficacy of conservative treatment for subacute ATRR in this phase. We conducted a retrospective review of 390 cases (385 patients) who had undergone primary Achilles tendon repair using the 4-strand Krachow method between January 2010 and August 2021. All patients were subjected to more than 12months of follow-up and were categorized into two groups based on the presence of subacute ATRR: Group 1 comprised 370 cases without ATRR, while Group 2 comprised 20 cases with ATRR. Following confirmation of ATRR, we immediately applied a below-knee cast in an ankle plantar flexed position (25°-30°), followed by bracing according to the same rehabilitation plan used for the primary repair. After administering conservative treatment to the patients with ATRR, we compared several outcome parameters between the two groups, including isokinetic plantar flexion power measured using a dynamometer, time required for a single heel raise (t-SHR), time needed for ten repetitive SHRs (t-SHR10), Achilles Tendon Total Rupture Score (ATRS), and Foot and Ankle Ability Measure (FAAM) scores. The baseline timepoints for Groups 1 and 2 were the dates of the primary repair and the re-injury event. After primary Achilles tendon repair, subacute ATRR occurred in 5.1% of patients. There were no significant differences between the groups in terms of t-SHR and t-SHR10 (P = 0.281, 0.486). Similarly, the isokinetic dynamometer measurements revealed no significant differences in peak torque for plantar flexion at angular velocities of 30°/s and 120°/s, both in absolute values and as a percentage of the contralateral side, between the groups (P > 0.05 for each). However, ATRSs were significantly lower in Group 2 compared to Group 1 before 6months (P < 0.05), as were FAAM-Activities of Daily Living scores at 6months (P < 0.05). After 12months, there were no significant differences in these scores between the two groups (both P > 0.05). Conservative treatment for subacute ATRR following primary Achilles tendon repair yields clinical outcomes comparable to those without ATRR. Therefore, we recommend that surgeons consider relying on the patient's natural healing capabilities rather than opting for aggressive surgical interventions, as expediting such operations may be unnecessary for subacute injuries.

Conservative Treatment Outcomes for Achilles Tendon Re-Rupture Occurring in the Subacute Phase after Primary Repair

Category: Ankle; Sports Introduction/Purpose: Achilles tendon re-rupture (ATRR) during the subacute postoperative phase is the rupture of the repaired site combined with suture material failure induced by an unexpected traumatic event during postoperative months one to three after primary Achilles tendon repair. This study aimed to determine the effectiveness of conservative treatment for subacute ATRR. Methods: We retrospectively reviewed 390 cases (385 patients) who underwent primary Achilles tendon repair between January 2010 and August 2021. All patients had more than 12 months of follow-up and were divided into two groups based on the development of subacute ATRR (Group 1: 370 cases without ATRR; Group 2: 20 cases with ATRR). Then, we compared several outcome parameters between the groups after administering conservative treatment to those with ATRR. The baseline timepoints in Groups 1 and 2 were the primary repair and re-injury dates. Results: After primary Achilles tendon repair, 5.13% of patients experienced subacute ATRR. The time to performing a single heel raise (SHR) and performing ten repetitive SHRs did not differ between the groups (P = 0.281, 0.486). Likewise, isokinetic dynamometer results showed that the peak torque of 30o/s and 120o/s plantar flexions (the absolute value and the percentage to the contralateral side) also did not differ between the groups (P &gt;0.05, each). However, the early Achilles tendon Total Rupture Score scale and the Foot and Ankle Ability Measure scores before six months were significantly lower in Group 2 than in Group 1 (both P &lt; 0.05); at 12 months, the scores did not differ between the two groups (both P &gt;0.05). Conclusion: Conservative treatment for subacute ATRR after primary Achilles tendon repair has comparable clinical outcomes to those without ATRR.

Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94). The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level III, retrospective comparative study.

First 30 Days Wound-Related Complications in Young Smokers Following Primary Achilles Repair

The Achilles tendon is frequently injured in the young to middle aged population. Previous studies have shown that there is an increased risk of delay in postsurgical wound healing amongst tobacco smoking patients with Achilles tendon injury.This study utilized the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. We included patients between the ages of 18 and 35 years who underwent primary Achilles tendon repair between years 2011 and 2020. The procedure type (with or without graft, CPT 27650 and 27652), patient demographics, and comorbidities were included. Primary outcomes of interest were 30-day readmission, minor complications, outcomes related to wound healing (wound disruption, superficial surgical site infection, deep incisional surgical site infection, organ-space site infections) and reoperations within 30 days of index surgery.A total of 1944 patients met the inclusion criteria for this study. One thousand six hundred and fifty-nine patients were nonsmokers, while 285 were smokers. Logistic regression showed no differences between smokers and nonsmokers (reference group) for 30-day readmission, reoperation, and minor complications. However, Black non-Hispanic patients were found to be 0.3 times (95% confidence interval: 0.1, 0.98) as likely to develop minor complications as compared to the White non-Hispanic patients.Wound-related complications after Achilles tendon repair remain low in younger (18-35 years) patients. When comparing clinical outcomes between nonsmokers and smokers, we found no statistically significant difference in this retrospective study.

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

Category:Ankle; SportsIntroduction/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.

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

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.

Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair

To assess the effects of medical comorbidities on the incidence of surgical site infection following primary Achilles tendon repair. A secondary aim was to assess the effects of specific medical comorbidities on the cost and extent of healthcare utilization related to surgical site infection following primary Achilles tendon repair. 24,269 patients undergoing primary Achilles tendon repair between 2005 and 2012 were examined. Current Procedural Terminology codes for primary Achilles tendon repair, and incision and drainage were used to search for and compile patient data from the United Healthcare Orthopedic and Medicare databases. Primary outcome measures regarding surgical site infection following primary Achilles tendon repair included the rate of occurrence, cost, and duration of treatment. Patients with one or more preexisting medical comorbidities at the time of surgery had an increased rate of surgical site infection compared to those without. Diabetes and vascular complications were associated with the highest surgical site infection rates. The rate of surgical incision and drainage was higher in patients with cardiac arrhythmias and uncomplicated hypertension. The presence of a medical comorbidity significantly increased the cost and duration of surgical site infection treatment. Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. A better understanding of the relationship between each medical comorbidity and surgical site infections following Achilles tendon repair may be ascertained with additional prospective studies, thus, allowing for a more accurate evaluation and stratification of surgical candidates to improve patient outcomes. Retrospective cohort study, Level III.

Value of Supine Positioning in Repair of Achilles Tendon Ruptures

Category: Hindfoot Introduction/Purpose: The optimal method of Achilles tendon repair remains undefined. Few previous studies have quantified the financial expenses of Achilles tendon repairs in relation to functional outcomes in order to assess the overall value of the accepted repair techniques. The purpose of this study is to demonstrate the value of supine positioning during open repair (OS) of acute Achilles tendon ruptures through the quantification of operative times, costs, and outcomes in comparison to the commonly performed percutaneous prone (PP) repair technique. Methods: A retrospective review was conducted on 67 patients undergoing OS and 67 patients undergoing PP primary Achilles tendon repair with two surgeons at four surgical locations. Total operating room usage times and operating times were collected from surgical site records. Total operating room times were used to estimate the costs of room usage and anesthesia, while costs of repair equipment were collected from the respective manufacturers. Patients undergoing OS repair completed the Foot and Ankle Ability Measure (FAAM) questionnaire, with activities of daily living (ADL) and sports subscales, Short Form-12 (SF-12), with mental (MCS) and physical (PCS) health subcategories, and the visual analog scale (VAS) for pain preoperatively and at final follow-up. Results: Even with a significantly longer mean surgical time (P=.035), OS repairs had a shorter duration of total operating room time when compared to that of PP repairs (58.4 versus 69.7 minutes, P&lt;.001). Estimated time-dependent costs were lower in OS repairs ($739 versus $861 per procedure, P&lt;.001), while the estimated average total per procedure cost was also lower for OS repairs ($801 versus $1,910 per procedure, P&lt;.001). For patients undergoing OS repair, FAAM-ADL (P&lt;.001), FAAM-Sports (P&lt;.001), SF-12-PCS (P&lt;.001) all increased and VAS grades (P&lt;0.001) decreased from time of initial encounter to final follow-up and were comparable to reported outcomes in the current literature. The complication rate in OS repairs (6.0%) was lower than PP repairs (11.9%), with revisions only occurring in the latter technique. Conclusion: Performing open Achilles tendon repair in the supine position offers substantial value, or “health outcomes achieved per dollar spent”, to providers due to decreased total operating room times and costs with satisfactory functional outcomes.

Low Risk for Local and Systemic Complications After Primary Repair of 1626 Achilles Tendon Ruptures.

Historically, Achilles tendon repairs and other surgeries about the hindfoot have demonstrated a significantly higher rate of wound healing complications and surgical site morbidity. The purpose of this study was to evaluate the comprehensive complication profile and risk factors for adverse short-term, clinical outcomes after primary repair of Achilles tendon ruptures. Between the years 2005 and 2014, all cases of primary Achilles tendon repair (Current Procedural Terminology code 27650) entered into the National Surgical Quality Improvement Project (NSQIP) database were extracted for analysis. Primary outcomes of interest were rates of total complication, reoperation, and rerupture within 30 days of index surgery. Independent risk factors associated with these selected endpoints were assessed with chi-square and logistic regression analysis and odds ratios with 95% confidence intervals were used to express relative risk. Of 1626 patients with an average age of 44 years (SD 13.3), the average ASA classification was 1.69 and hypertension (20.7%), morbid obesity (8.3%), and diabetes (4.9%) were among the most common medical comorbidities. A total of 28 (1.7%) patients sustained perioperative complications, including 1.3% with local complications (0.7% superficial wound infection, 0.4% wound disruption) and no cases of peripheral nerve injury or early repair failure. Systemic complications occurred in 0.4%, most commonly with deep venous thrombosis or nonfatal thromboembolism. Preoperative albumin was independently associated with an increased risk of local wound complications (odds ratio [OR] 28.67; 95% CI 1.42-579.40; P = .029). Chronic obstructive pulmonary disease (OR 22.33, 95% CI 2.49-199.81; P = .006) and bleeding disorder (OR 14.83, 95% CI 1.70-129.50; P = .015) were more likely to result in a systemic complication, and preoperative creatinine correlated with an increased risk of any complication (OR 6.11, 95% CI 1.15-32.34; P = .033). In total there were 5 (0.3%) readmissions with 2 (0.1%) unplanned reoperations attributed to local wound complications. Among a broad-based demographic of the United States, the rate of local wound complications was exceedingly low in the short-term perioperative period, although this risk may be significantly magnified with subtle decreases in albumin levels. Preoperative risk stratifications should carefully scrutinize for subtle abnormalities in nutritional parameters and renal function prior to undergoing Achilles surgery. Therapeutic, Level II: Prospective, comparative trial.

Co-Morbidities Are Associated with Increased Cost, Infection Rates, and Duration of Treatment after Primary Achilles Tendon Repair

Category: Sports. Introduction/Purpose: The purpose of this study was to assess the rate of surgical site infection (SSI) and surgical irrigation and debridement (I&amp;D) after primary Achilles tendon repair. Secondary objectives were to assess the potential effect(s) of medical comorbidities on cost and duration of treatment of SSI after Achilles tendon repair. Methods: De-identified patient insurance records within the government and private national insurance orthopaedic datasets were searched between 2005-2012. The Current Procedural Terminology (CPT) code was used to identify primary Achilles tendon repair and I&amp;D. Subsequently, post-operative SSIs and comorbidities were examined by searching corresponding International Classification of Disease Ninth Revision, Clinical Modification (ICD-9-CM) codes. Results: 24,269 primary Achilles tendon repairs were identified. Overall, there was a significantly increased rate of SSI if a medical comorbidity was present at the time of surgery compared to those without a comorbidity (17.96% vs. 5.96%, p &lt; 0.0001). Patients with diabetes and vascular complications had the highest SSI rate (OR 7.85, CI 6.25-9.86, p &lt; 0.001), followed by peripheral vascular disease, diabetes with peripheral neuropathy, history of drug abuse, fluid and electrolyte abnormalities, obesity, and uncomplicated diabetes. There was higher rate of surgical I&amp;D in patients with cardiac arrhythmias and uncomplicated hypertension. There was a significant increase in cost of SSI treatment ($6,004.09 vs. $4,184.62, p=0.006) and duration of treatment (8.41 days vs. 5.54 days, p &lt; 0.001) if a medical comorbidity was present in Achilles tendon patients with SSI. Conclusion: An analysis of a large cohort of patients undergoing Achilles tendon reconstruction revealed that having certain medical comorbidities conferred a significantly greater risk for developing SSI, which increased both the cost of subsequent care and duration of treatment. Furthermore, with the advent of “value”/outcomes based care being linked to reimbursement, SSI is a one measure being used by the Centers for Medicare &amp; Medicaid Services and private insures to determine appropriate orthopaedic care. Thus, patients with modifiable risk factors should be referred for medical management prior to surgery or deferred to a non-operative treatment program to reduce the risk of SSI after Achilles tendon repair.

Evaluation of Brake Response Time Following Primary Achilles Tendon Repair Surgery

Category: Sports. Introduction/Purpose: Although surgical repair of Achilles tendon ruptures are common procedures, there are no studies investigating postoperative driving safety in these patients. Active contracture of the Gastroc-soleus-Achilles mechanism is required during a braking maneuver while driving. There is concern that these patients may be hesitant to rapidly apply braking pressure, putting themselves and others at potential risk. The purpose of this study was to evaluate postoperative brake response time (BRT) in right-sided Achilles rupture repair patients as a means to determine driving preparedness. BRT is defined as the time, in milliseconds, between presentation of a perceived hazardous stimulus and the application of pressure to the brake pedal in a driving simulator model. We hypothesized patients would demonstrate BRTs comparable to control subjects 6-week after repair. Methods: Following IRB approval, 50 right-sided acute primary Achilles rupture repair patients were prospectively identified and enrolled. All patients were managed with a standardized postoperative protocol. Exclusion criteria were age under 18, those not in possession of a valid driver’s license, those undergoing non standard open primary repair, and those declining to participate in the study. All patients were tested for their BRT utilizing a validated driving simulator at their 6-week postoperative follow-up appointment. Those patients that failed to achieve a safe brake response time less than 0.850 seconds were re-tested at weekly intervals until a safe breaking time was achieved. The passing brake response time of 0.850 seconds was determined from the published control data and from testing 20 healthy volunteers in the same simulator. At each testing, patients also filled out an AOFAS Ankle Hindfoot Scale, an Achilles Tendon Total Rupture Scale (ATRS) Questionnaire and a Driving Preparedness survey. Results: Each subject underwent 3 sequential drive-braking simulation tests, with their BRT being calculated as an average of the 3 times. At six weeks post repair the overall average BRT for all 50 patients was 0.658 seconds. 47 of the 50 patients (94%) demonstrated safe average BRT at their 6-week post operative testing of equal to or less than 0.850 seconds, with the remaining 3 patients achieving a safe BRT after 7 weeks. All 47 patients whose test demonstrated a safe BRT at 6 weeks responded in their survey that they “Agreed” or “Strongly Agreed” they were ready to drive at the time of testing. At six weeks post repair, the average AOFAS-AH score was 78.7/100, and the average ATRS score was 54.0. Conclusion: The present study revealed that 94% of primary right-sided acute Achilles tendon rupture repair patients were able to demonstrate a safe BRT comparable to those of healthy control subjects 6 weeks after their surgical procedure, and all by seven weeks following surgery. 100% of these patients also reported that after completing the test, they felt ready to return to driving. Therefore, we believe that it is reasonable to offer primary Achilles tendon repair patients an estimate of 6-weeks recovery time before driving.

Outcomes of acute Achilles tendon rupture repair with bone marrow aspirate concentrate augmentation.

Optimal treatment of acute Achilles tendon ruptures remains controversial. Positive results using stem-cell-bearing concentrates have been reported with other soft-tissue repairs, but no studies exist on outcomes of bone marrow aspirate concentrate (BMAC) augmentation in primary Achilles tendon repair. We reviewed patients with sport-related Achilles tendon ruptures treated via open repair augmented with BMAC injection from 2009 to 2011. Data on operative complications, strength, range of motion, rerupture, calf circumference and functional improvement through progressive return to sport and the Achilles tendon Total Rupture Score (ATRS) were analysed. A total of 27 patients (28 tendons) treated with open repair and BMAC injection were identified (mean age 38.3 ± 9.6 years). At mean follow-up of 29.7 ± 6.1 months, there were no reruptures. Walking without a boot was at 1.8 ± 0.7 months, participation in light activity was at 3.4 ± 1.8 months and 92% (25 of 27) of patients returned to their sport at 5.9 ± 1.8 months. Mean ATRS at final follow-up was 91 (range 72-100) points. One case of superficial wound dehiscence healed with local wound care. No soft-tissue masses, bone formation or tumors were observed in the operative extremity. Excellent results, including no re-ruptures and early mobilisation, were observed in this small cohort with open Achilles tendon repair augmented by BMAC. No adverse outcomes of biologic treatment were observed with this protocol. The efficacy of BMAC in the operative repair of acute Achilles tendon ruptures warrants further study. IV - Therapeutic.

Collagen Ribbon Augmentation of Achilles Tendon Tears: A Biomechanical Evaluation

Early motion of a repaired Achilles tendon has been accepted to improve both clinical and biomechanical outcomes. It has been postulated that augmenting a primary Achilles tendon repair with a collagen ribbon will improve the repair construct's initial strength, thereby facilitating early motion. The purpose of the present study was to compare the failure load of Achilles tendon defects repaired with suture, with or without augmentation with a collagen ribbon. Ten matched pairs of cadaveric feet and tibiae underwent simulated Achilles tendon tear in the watershed area and were then repaired with 4-strand Krackow sutures only or were sutured and augmented with a box weave collagen ribbon xenograft. The specimens were prepared for testing by keeping the insertion of the Achilles to the calcaneus intact and dissecting the gastrocnemius at its origin, leaving the repair undisturbed. The mean load at failure for the augmented (suture plus collagen ribbon) specimens was 392.4 ± 74.9 N. In contrast, the mean load at failure for the suture-only (control) construct was 98.0 ± 17.6 N (p < .001). The augmented specimens demonstrated a greater mean strength of 4.1 ± 0.9 N (range 3.2 to 5.6). After cyclic loading, the mean gap across the Achilles repair was significantly smaller in the augmented group than in the control group (p = .006). We have concluded that box weave collagen ribbon augmentation of the primary suture Achilles tendon repairs can provide enhanced gap resistance and strength under cyclic loading and ramped tensile testing.

Primary Achilles Tendon Repair with Mini-Dorsolateral Incision Technique and Accelerated Rehabilitation

No consensus exists for the best primary repair of acute Achilles tendon ruptures. Problems with wound healing and nerve damage can occur. Prolonged immobilization leads to stiffness and calf atrophy. This study assesses the clinical outcome of acute Achilles tendon repairs using a mini-dorsolateral incision followed by a rapid rehabilitation program. A consecutive series of acute Achilles tendon ruptures repaired using a mini-dorsolateral incision were reviewed with a minimum 12 months follow up. Fifteen patients with an average age of 44 (range, 32 to 60) years were followed an average of 45 (range, 14 to 72) months. Two modified, buried core high strength sutures were placed in each torn end of the Achilles tendon reinforced with a running circumferential whip-stitch. Ankle Hindfoot scores, single toe raises, calf circumference, and adverse events were recorded. An accelerated postoperative rehabilitation protocol was followed. Postoperative AOFAS Ankle Hindfoot scores averaged 98.3 [39 pain; 49.6 function; 9.3 alignment]. All patients could single heel raise. Eight of 15 demonstrated atrophy with an average calf circumference loss of 1.0 cm. The only postoperative complication was one case of superficial cellulitis successfully treated with oral antibiotics. There were no sural nerve injuries, wound break down, or re-ruptures at final followup. The repair of acute Achilles tendon ruptures through a minimal lateral incision provided excellent functional outcomes, avoided complications including sural nerve injury, and allowed a return to sports between 4 to 6 months.

Short- and long-term outcomes of primary Achilles tendon repair in cats: 21 Cases

To evaluate the short- and long-term outcomes of surgically repaired Achilles tendons in cats. Twenty-one cats that underwent surgical repair of Achilles tendon injuries were retrospectively examined. Signalment, type of injury, time from injury to surgery, the surgical repair, complications, and long-term outcomes were recorded. Statistical comparisons were made between traumatic and atraumatic injuries using Student's paired t-tests. Both traumatic and atraumatic causes of disruption were equally represented and female cats were significantly over-represented. Type I and Type IIc injuries were found in cats, but the type did not affect short- or long-term outcome. A complication rate of 33% was identified and was always attributable to the method of external coaptation. None of the cats that were augmented with a splint developed complications, however complications did occur in those with transarticular external skeletal fixators. Long-term clinical outcome found an 84% overall success rate and a 79% success rate for cats with Type IIc injuries. A significantly shorter time from injury to surgery was identified for traumatic injuries, but not for age, weight, or long-term outcome. Surgical correction resulted in excellent functional outcome in all cases but one, and should be considered in both complete and partial disruption of the Achilles mechanism in cats. A direct comparison between surgical and conservative management of Type IIc injuries in cats should be considered to determine which method is most appropriate to manage these injuries.

Achilles Tendon Repair in Dogs Using the Semitendinosus Muscle: Surgical Technique and Short‐Term Outcome in Five Dogs

To describe augmentation of primary Achilles tendon repair using suture with a semitendinosus muscle flap and report outcome in 5 dogs. Prospective clinical study. Dogs (n=5) with Achilles tendon rupture (n=6). After tendon repair with #2 polypropylene in a 3-loop pulley suture pattern, the lateral one-half of the semitendinosus muscle was transected from the ischium, rotated distally then sutured with #2 polypropylene to the calcaneus in a 3-loop pulley pattern. The epitenon was sutured to the muscle flap fascia with interrupted sutures. All dogs had a bivalved cast for 2 weeks then a cranial splint for 2-6 weeks. Lameness scores (0=stands and walks normally to 4=non-weight-bearing lameness, plantigrade stance on affected pelvic limb) were determined every 2-3 weeks postoperatively for 12 weeks. Outcome was determined from telephone questionnaire of owners. Four had lameness scores of 0, the 5th had a score of 1 at 12 weeks. Three owners were very satisfied with outcome. Minor complications included cast sores (2 dogs), infection (2), and acute swelling (1); 1 major complication occurred (infection resulting in reoperation). Semitendinosus flap augmentation resulted in early return to function without prolonged postoperative immobilization. Three dogs returned to full work/activity after repair. Augmentation of primary Achilles tendon repair with a semitendinosus flap can be considered in dogs with chronic rupture but further investigation of the long-term outcome using this technique is needed.

Potential Risk of Rerupture in Primary Achilles Tendon Repair in Athletes Younger than 30 Years of Age

Background Complete Achilles tendon ruptures are found more often in athletes who participate in sports involving explosive acceleration or maximal effort. In most studies, the consensus for athletes is surgery. This form of treatment has been shown to exhibit the best functional performance with a lower rerupture rate. Hypothesis Achilles tendon ruptures in a young population (<30 years) have a higher rerupture rate than similar injuries in an older age group (31-50 years), in which the injury is more common. Study Design Cohort study; Level of evidence, 4. Methods Retrospective study was carried out by chart review. Magnetic resonance images were obtained comparing appearance of repair in young and old patients at 8 to 12 weeks after operation. Results There were a total of 4 reruptures in the 89 Achilles tendon repairs. This was an overall rerupture rate of 4.5%, which was consistent with the literature. When the reruptures were critically analyzed, it was noted that the 4 reruptures of the repaired tendon occurred in a young population. Of the 89, there was a subgroup of athletes (n = 24) who were 30 years of age or younger at the time of injury. The incidence of rerupture for these individuals was 16.6%. In the remaining athletes (n = 65) older than 30 years, the incidence of rerupture was zero. There were no significant differences (P=. 05) in all parameters measured (average days in a boot, average days to active range of motion, average time to full weight-bearing, average days to bike or use a stair climbing machine, average return to sports) between age groups except in the time from injury to surgery (7.1 days, for athletes = 30 years vs 2.65 days for athletes >31 years). Conclusions The results of Achilles tendon repair with an early weightbearing and an early range of motion rehabilitation program are good. However, caution may need to be taken in the younger athlete (= 30 years) during rehabilitation. Clinical Relevance Although the authors recommend aggressive rehabilitation for Achilles tendon repairs, caution should be observed in the younger athlete.

Early full weightbearing and functional treatment after surgical repair of acute achilles tendon rupture.

We prospectively evaluated the clinical outcomes of 20 patients (mean age, 42.8 years) with early full weightbearing and functional treatment after surgical repair of acute Achilles tendon rupture according to a prospective intra- and postoperative protocol. All patients underwent open repair using a Kessler-type suture and simple apposition sutures. The postoperative regimen included a plantigrade splint for 24 hours and 6 weeks of early full weightbearing in a removable walker. All patients were evaluated with clinical and ultrasound examination and according to a new scoring system at 3, 6, and 12 months after repair. After 3 months, the score averaged 73 of 100 points; after 6 months, 86; and after 1 year, 94. All patients reached the same level of sports activities as preoperatively and demonstrated no significant difference in ankle mobility and isokinetic strength. There were no reruptures. One patient had a deep venous thrombosis 3 weeks after the operation after having prematurely stopped thromboprophylaxis. We believe that early careful ankle mobilization and full weightbearing in a removable walker after primary Achilles tendon repair does not increase the risk of rerupture. An accelerated rehabilitation program improves early foot function with excellent recovery of plantar flexion strength and amplitude.