Background: Various techniques may be used to repair Achilles tendon ruptures; however, we contend that using the strongest suture with the least amount of suture material is ideal.
Methods: To compare the strength of 2-0 FiberLoop (Arthrex Inc, Naples, Florida) and #2 Ethibond (Ethicon Inc, Somerville, New Jersey) suture materials in Achilles tendon repairs, 12 Achilles tendons were harvested from cadavers aged 18 to 62 years (median age, 42 years). The tendons were transected and repaired using a modified Krackow suture technique. All of the right limbs were repaired with 2-0 FiberLoop, and the contralateral side was repaired with #2 Ethibond. The specimens were mounted to a materials testing system, and the repairs were pulled to failure in an anatomical direction.
Results: The mean ± SD yield loads of 2-0 FiberLoop and #2 Ethibond were 233 ± 48 N and 134 ± 34 N, respectively (P = .002). The mean ± SD ultimate load of 2-0 FiberLoop was 282 ± 58 N, and that of #2 Ethibond was 135 ± 33 N (P < .001). The cross-sectional area of one pass of 2-0 FiberLoop was calculated to be 0.21 mm2, and one pass of #2 Ethibond was 0.28 mm2.
Conclusions: The smaller-caliber 2-0 FiberLoop was significantly stronger than #2 Ethibond. This study suggests that there is no advantage to using the traditional larger suture material for Achilles tendon repairs; however, further clinical testing is needed to determine the optimal repair technique. (J Am Podiatr Med Assoc 100(3): 185–188, 2010)
In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation.
We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016.
During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22–180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient).
In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.
The Achilles tendon of the patient with Charcot’s foot neuroarthropathy has significantly altered physical properties compared with a normal tendon. Twenty-nine Achilles tendons from patients with Charcot’s foot (n = 20) and non-Charcot’s foot controls (n = 9) were loaded onto a biomechanical testing instrument. The biomechanical properties of the Charcot and control tendons were determined and the tendons were evaluated for differences in ultimate tensile strength and elasticity (Young’s modulus). Biomechanical test data show that there is a significant difference in ultimate tensile strength and elasticity between tendons of patients with Charcot’s foot and those of non-Charcot’s controls. The term diabetic tendo Achillis equinus is introduced as a new finding in diabetic neuroarthropathy. (J Am Podiatr Med Assoc 95(3): 242–246, 2005)
Surgical or nonsurgical treatment of an Achilles tendon rupture includes a period of immobilization that is a well-documented risk factor for deep venous thrombosis (DVT). The DVT is a source of morbidity in orthopedic surgery because it can progress to pulmonary embolism. The aim of this study was to investigate the incidence of DVT and pulmonary embolism after surgical treatment of an Achilles tendon rupture.
A retrospective analysis was made of patients who underwent surgical treatment of Achilles tendon rupture between January 1, 2006, and November 30, 2014. Patient data were collected from the hospital medical record system.
Of 238 patients with a mean age of 39 years (range, 18–66 years), 18 (7.6%) were diagnosed as having symptomatic DVT. The average body mass index of the patients with DVT was 31.8 (range, 24–33). Of the patients with DVT, 11 were older than 40 years and two-thirds had a body mass index of 30 or greater. Pulmonary embolism was diagnosed in four patients (1.7%), none of whom had DVT symptoms.
Venous thrombosis continues to be a major cause of morbidity and mortality in postoperative patients. Limited data are available for the use of thromboprophylaxis in foot and ankle surgery. In light of the literature review and results of this study, we suggest that routine thromboembolism prophylaxis should be considered for patients with Achilles tendon rupture.
Metabolic disorders are known to alter the mechanical properties of tendons. We sought to evaluate the prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with type 2 diabetes mellitus (T2DM) without peripheral neuropathy.
We recruited 43 patients with T2DM and 40 controls. Neuropathy was excluded with the Michigan Neuropathy Scoring Instrument. Bilateral ultrasonography of the Achilles tendon enthesis was performed.
Patients with T2DM had a higher prevalence of hypoechogenicity (26.7% versus 2.5%; P = .0001), entheseal thickening (24.4% versus 8.7%; P = .007), and enthesophytes (74.4% versus 57.5%; P = .02). No differences were found in the number of patients with erosions (1.2% versus 0%; P > .99), cortical irregularities (11.6% versus 3.7%; P = .09), bursitis (5.8% versus 3.7%; P = .72), or tears (2.3% versus 1.2%; P > .99). The mean ± SD sum of abnormalities was higher in patients with T2DM (1.5 ± 1.1 versus 0.7 ± 0.6; P < .0001), as was the percentage of bilateral involvement (72.1% versus 45.0%; P = .01). Mean ± SD thickness did not differ between patients and controls (4.4 ± 1.1 mm versus 4.2 ± 0.8 mm; P = .07).
According to our data, there is an elevated prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with T2DM independent of peripheral neuropathy.
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)
Background: Many authors have highlighted the role of muscle strength imbalance around the ankle in the development of recurrent clubfoot following Ponseti treatment. However, this possible underlying mechanism behind recurrence has not been investigated sufficiently to date. This study aimed to explore whether there is a relationship between Achilles tendon elongation and recurrent metatarsus adductus deformity in children with unilateral clubfeet treated by the Ponseti method.
Methods: A retrospective chart review was performed on 20 children (14 boys and six girls; mean age, 7 years; age range, 5–9 years) with a recurrent metatarsus adductus deformity treated by the Ponseti method for unilateral idiopathic clubfoot. At the final follow-up, isometric muscle strength was measured using a portable, hand-held dynamometer in reciprocal muscle groups of the ankle. The length of the tendons around the ankle was measured ultrasonographically.
Results: The plantarflexion-to-dorsiflexion ratio was lower on the involved side (P = .001). No significant differences in the strength ratio of inversion to eversion were found (P = .4). No difference was observed in lengths of tibialis anterior and posterior tendons (P = .1), but the Achilles tendon was longer on the involved side (P = .001; P < .01). A significant negative correlation was discovered between involved-to-uninvolved Achilles tendon length ratios and involved-to-uninvolved plantarflexion strength ratios (r = –0.524; P = .02)
Conclusions: Achilles tendon elongation may be a contributor to the muscle imbalance in clubfeet with relapsed forefoot adduction treated by the Ponseti technique.
Background: Adhesions after tendinopathy in individuals who perform physical work and those physically active in middle age are a challenging problem for orthopedic surgeons. We evaluated the effects of human-derivated amniotic membrane on tendon healing, adhesions, angiogenesis, and the inflammatory process.
Methods: Thirty-five rats were divided evenly into five groups, and the left lower extremity was used in this study. No interventions were applied to the control group (group 5). In the other groups, Achilles tendons were partially cut to the midline. Then, primary repair (group 1), amniotic membrane treatment with no repair (group 2), primary repair and amniotic membrane treatment (group 3), or secondary healing with no repair (group 4) was performed.
Results: Use of amniotic membrane in tendon healing resulted in decreased adhesion formation and positive effects on collagen sequencing and anti-inflammatory effects. In addition, for the vascular endothelial growth factor evaluation there was no difference among the amniotic membrane repair groups, but there was an increase in vascular endothelial growth factor positivity compared with the control group.
Conclusions: These data show that amniotic membrane treatment can alter biological behavior and induce surface-dependent angiogenesis and can have angiogenetic effects on ischemia and inflammation.
Achilles tendon rupture is a common athletic injury that results in a painful and antalgic gait. Flexor hallucis longus tendon transfer through arthroscopic, single-incision, or double-incision techniques is used as a treatment approach to address this rupture; however, no studies have compared postoperative complications between these three techniques. A systematic search of published articles was conducted using keywords “Achilles rupture,” “flexor hallucis tendon,” “transfer,” and “recovery.” Articles were then selected based on their title, abstract, and content following full-text review. From each article's reported surgical outcomes, a comparison was made between arthroscopic and single- and double-incision postoperative complications using a χ2 test with significance set at a value of P < .05 followed by post hoc analysis. The arthroscopic approach maintained the lowest rate of postoperative complications, followed by the single- and double-incision techniques. A significant difference in the number of postoperative complications was found between all incisional approaches. The pairwise comparisons, however, could not identify which incisional approaches significantly differed between each other. A reduction in postoperative complications places arthroscopy and the single-incision techniques as the preferred approaches for flexor hallucis longus tendon transfer following an Achilles tendon rupture. Although current literature shows arthroscopy to be superior to single- and double-incision methods, this review demonstrates the need for a greater number of published cases using arthroscopy to establish significance regarding postoperative complications.
Tendinopathies are common musculoskeletal disorders that often develop because of chronic loading and failed healing. Tendinopathy related to systemic inflammation has been less extensively examined. Furthermore, although the use of biological agents to treat tendinopathies continues to gain popularity, the use of amniotic fluid–derived allografts in outpatient settings to resolve tendinopathies requires further evaluation.
The focus of this case report is a 25-year-old man who presented for a second opinion, having been diagnosed with Haglund deformity and Achilles tendinopathy. At the time of presentation, he complained of 10 of 10 pain to the right Achilles tendon. He was treating the injury conservatively with intermittent use of a controlled ankle motion boot and working with physiotherapy for approximately 5 months before presentation. Diagnostic ultrasound along with magnetic resonance imaging indicated distal thickening of the Achilles tendon, substantial fluid and edema in the Kager fat pad, and retrocalcaneal erosions with bursitis. Conservative management did not resolve the symptoms. As an alternative to surgery, the patient elected to undergo an Achilles tendon injection of an amniotic fluid–derived allograft. Before and after the initial injection, a microdialysis catheter was inserted into the Achilles peritendinous space to sample local levels of extracellular matrix enzymes and growth factors important for tendon remodeling. The patient received considerable relief with the initial injection, but did not return to full strength. Over the subsequent 8 weeks, the patient was followed closely and was able to return to daily activities with minimal pain. He was not able to return to a more active lifestyle without further Achilles pain, so a second amniotic fluid–derived allograft injection was performed 8 weeks after the initial injection.
Injection of the initial allograft resulted in significant improvement, but not complete resolution of pain and swelling. Microdialysis findings suggested a reduction in peritendinous levels of the cytokine interlukin-6 in addition to changes in extracellular matrix regulatory enzymes. After 8 weeks of additional conservative therapy and a second injection, no further improvement in pain was noted.
Based on the clinical improvement of symptoms in this individual and the changes seen with microdialysis methodology, the authors find the use of amniotic fluid–derived allograft injection for treatment of Achilles pain in this patient to be a viable treatment. Additional comorbidities of systemic inflammatory polyarthritis and possible seronegative disease were addressed after rheumatology consultation with a variety of medications that provided the patient additional relief of his symptoms. The patient ultimately moved and was lost to further follow-up.