The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Augmented Repair of Acute Achilles Tendon Rupture Using an Allograft Tendon Weaving Technique Xiaowei Huang, MD 1, Gan Huang, MD 2, Ying Ji, MD 3, Rong guang Ao, MD 3, Baoqing Yu, MD 4, Ya long Zhu, MD 3 1
Postgraduate Student, Shanghai Medical College, Fudan University, Shanghai, China Surgeon, Department of Orthopaedics, Changhai Hospital, The Second Military Medical University, Shanghai, China Surgeon, Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, Shanghai, China 4 Professor, Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, Shanghai, China 2 3
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Achilles tendon rupture is a common injury, especially in those who are physically active. Although open surgery is a widely used option for the treatment of acute Achilles tendon rupture, the optimal treatment is still disputed. In our study, 59 patients with unilateral, closed, acute rupture of the Achilles tendon were treated by open surgery using an allograft weave to augment the repair. All the surgeries were performed within 1 to 4 days after injury. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was recorded as 91.20 (range 88 to 95), 95.34 (range 92 to 98), and 98.27 (range 97 to 99) at the 3-, 6-, and 12-month follow-up visit, respectively. At the final follow-up visit, the mean difference between the mid-calf circumference of the injured and uninjured legs was 0.19 (range 0.03 to 1.50) cm (p ¼ .43). At the final follow-up visit, the mean difference between the vertical distances from the plantar surface of the heel to the ground for the injured and uninjured lower extremities was 0.44 (range 0.03 to 0.5) cm (p ¼ .17). Augmented repair using the allograft tendon weaving technique provided satisfactory tendon strength and functional outcomes and a timely return to the patients’ activities. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle clinical outcome injury surgery
Rupture of the Achilles tendon is not rare, especially in active middle-age men, who account for approximately 35% of all Achilles tendon injuries (1), most of which are sports-related (2). The treatment options for acute Achilles tendon rupture include conservative therapy and percutaneous or open surgical repair. However, the optimal treatment remains controversial, and each of these 3 options has its inherent advantages and disadvantages (3–5). Conservative treatment has been recommended in some studies. According to a follow-up questionnaire of 487 patients, conservative treatment was regarded as the preferable option for most patients because of its relatively low incidence of repeat rupture and other complications and the good Achilles tendon total rupture scores (6). Taking postoperative rehabilitation protocols into consideration, a meta-analysis of randomized trials showed that conservative Financial Disclosure: This study was funded by the Outstanding Leaders Training Program of Pudong Health Bureau of Shanghai (grant PWR12013-01). Conflict of Interest: None reported. Drs X. Huang and G. Huang are first coauthors. Address correspondence to: Baoqing Yu, MD, Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, No. 2800, Gongwei Road, Huinan Town, Pudong New Area, Shanghai 201301, China. E-mail address: [email protected] (B. Yu).
treatment was preferable at centers equipped with functional rehabilitation facilities (7). In contrast, at centers at which range-of-motion protocols are not available, surgical repair should be considered because of its lower incidence of repeat rupture (7). However, the longer period of immobilization required for nonoperative treatment, compared with open surgery, reduces the tonicity of the Achilles tendon (8) and has been associated with relatively greater rates of repeat rupture (9), drawbacks that limit the use of nonoperative management. Ma and Griffith (10) described percutaneous, or minimally invasive, repair of the ruptured Achilles tendon in 1977. With such techniques, the postoperative cosmetic appearance is significantly improved owing to the smaller incisions, which prevent full exposure of the ruptured tendon ends, but minimize surgical disruption of the paratendinous tissues (9,10). Nevertheless, sural nerve entrapment and inadequate apposition of the tendon ends have been associated with percutaneous methods because of the lack of adequate exposure and direct visualization of the surgical field (11,12). Open surgery has seemed to be preferred by most surgeons for the treatment of Achilles tendon rupture, because it permits anatomic restoration of the tendon length and minimizes compromise of the tendon’s tensile strength, especially in young active patients (5,7,9). The prevalent techniques for open surgery have included variations on primary end-to-end
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.12.029
2
X. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 1. Preoperative T2-weighted magnetic resonance imaging scan.
reapproximation of the proximal and distal ends of the Achilles tendon, such as the Krackow and Lindholm techniques (2). Augmentation of primary end-to-end reapproximation, such as the Teuffer technique (2), has also been described. Augmentation will strengthen the mechanical properties of the repaired Achilles tendon, making earlier and more aggressive rehabilitation protocols possible, reducing the risk of calf atrophy, repeat rupture, and limited ankle motion. In the present report, we evaluated the clinical and functional outcomes of 59 patients who had experienced acute, closed Achilles tendon rupture treated using open surgical reapproximation augmented with an allograft tendon weaving technique. Patients and Methods The inclusion criteria for the present study were a diagnosis of acute Achilles tendon rupture preoperatively and the receipt of open surgery using the allograft tendon weaving technique to augment the surgical reconstruction. Patients with diabetes, autoimmune disorders, complications of the ipsilateral lower limb fracture or neurovascular injury, and repeat Achilles tendon ruptures were excluded. The diagnostic criteria for Achilles tendon rupture consisted of the clinical presence of a palpable gap in the tendon, a positive Thompson test result (13), and magnetic resonance imaging evidence showing the ruptured tendon (Figs. 1 and 2). All ruptures were acute and unilateral. From February 2011 to April 2013, 1 of us (G.H.) searched the medical records of 124 patients who had been diagnosed with “acute Achilles tendon rupture” and found 59 patients fulfilling the criteria, including 6 females (10.17%) and 53 males (89.83%), with an mean age of 36.2 (range 18 to 51) years, as shown in Table 1. All the patients came from the practice of 1 of us (B.Y.). All the surgeries were performed within 1 to 4 days after the acute injury and were performed by 1 of us (B.Y.). In 54 patients (91.53%), the injury occurred in the practice of sports, and in 5 (8.48%), the rupture had resulted from a fall from a height. After admission to the hospital, all the patients received symptomatic treatment, including a short-leg cast to temporarily immobilize the affected limb and underwent magnetic resonance imaging to thoroughly evaluate the extent of the tendon damage. The specific site of the rupture was 3 to 6 cm proximal to the tendon’s insertion into the calcaneus in all 59 patients. One of us (G.H.) abstracted the data from the medical records to select the patients for the
Fig. 2. Preoperative T1-weighted magnetic resonance imaging scan.
investigation; 3 of us (Y.Z., R.O., Y.J.) assessed the patients’ outcomes; 1 of us (B.Y.) performed the surgeries; and 1 of us (X.H.) analyzed the data and wrote the report. In an attempt to limit biases, however, those of us who were not involved in the surgeries conducted the follow-up assessments. Surgical Procedure With the patient prone and under lumbar spinal or continuous epidural anesthesia, with a tourniquet applied to the ipsilateral thigh, routine disinfection of the surgical field and the contralateral limb was undertaken. The contralateral lower extremity was prepared to compare the tension in the Achilles tendon on both sides
Table 1 Patient characteristics (N ¼ 59 patients) Characteristic Sex Male Female Cause of injury Sports-related Falling down Duration of surgery (min) Mean Range Interval to recovery (wk) Mean Range Follow-up duration (y) Mean Range Intraoperative blood loss (mL) Mean Range Data presented as n (%), unless otherwise noted.
Value 53 (89.83) 6 (10.17) 54 (91.53) 5 (8.47) 42 35 to 80 11.2 11 to 15 2.1 1 to 3 26.30 20 to 30
X. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 4. Absorbent sutures were used to secure the allograft tendon where the graft was inserted through the tendon.
Fig. 3. Horsetail-like rupture 5 cm above the tendon insertion into the calcaneus in a 35year-old male patient with a sports-related injury.
during surgery. With the ipsilateral knee held in 30 flexion and ipsilateral foot in 10 plantar flexion at the ankle, the proximal and distal ends of the tendon were initially reapproximated, and suture tension was reduced when suturing the ruptured tendon. Making a posterior longitudinal incision parallel to the lateral border of the Achilles tendon, the skin, subcutaneous fat, and superficial fascia and paratenon layers were dissected layer by layer, with care taken not to compromise the sural nerve. Attention was given to maintain the aponeurosis as intact as possible when the nonviable portions of the tendon were debrided and the surrounding adhesions released. The ruptured tendon ends displayed a horsetail appearance in most cases (Fig. 3), which was irregular and ragged, and this is one of the reasons a full, extensile exposure can be very useful, because it enables the surgeon to fully inspect and reorganize the tendon ends. The proximal and distal ruptured ends were shaped into a regular configuration to enable homogenous distribution of tension across the reconstruction. The tendon ends were initially reapproximated with interrupted, 3-0, absorbable sutures crisscrossed within the body of the proximal and distal segments of the tendon. A long flexor allograft tendon, with the length ranging from 20 to 28 cm, was inserted through the distal segment of the tendon approximately 1 cm proximal to the insertion into the calcaneus and reinforced with 3-0 absorbable sutures in an interrupted fashion in the insertion sites (Fig. 4). The length of the allograft tendon used to reinforce the end-to-end reapproximation of the Achilles tendon depended on the size of the ruptured Achilles tendon. After the allograft was secured in the distal segment of the tendon, it was woven in a shoelace pattern through the proximal portion of the distal segment of the tendon, across the rupture interface, and then in a shoelace fashion from distally to proximally in the proximal portion of the Achilles tendon (Fig. 5) (14). The allograft weave should cross the rupture site at least once and should be secured in the proximal segment with the same interrupted sutures that were used in the distal segment. On completion of the weave, the proximal and distal ends of the Achilles tendon were secured at the proper physiologic tension (determined by comparison with the contralateral, uninjured lower extremity) using a
modified Krackow suture (2) of 2-0 with nonabsorbable suture (Fig. 6). Thereafter, anatomic layer closure proceeded from the paratenon to the superficial fascia and subcutaneous fat to the dermis, and a sterile bandage and short-leg plaster cast were used to immobilize the injured foot and ankle in a neutral position. A window was also left in the cast for dressing changes. The patients’ postoperative care entailed suture removal at the end of the second postoperative week, with the plaster cast removed at 4 weeks postoperatively and exercises for strength, range of motion, and proprioception initiated. At the end of the sixth postoperative week, the patients were allowed to walk with partial weightbearing facilitated by the use of crutches. Finally, patients were encouraged to undertake full weightbearing after 8 weeks of postoperative care.
Follow-Up Examinations The mean follow-up duration was 2.2 (range 1 to 3) years. During the follow-up period, the interval needed to return to the preinjury activity levels was recorded, and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score (15,16) was recorded at 3, 6, and 12 months after surgery. The results were graded as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor (
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Augmented Repair of Acute Achilles Tendon Rupture Using an Allograft Tendon Weaving Technique Xiaowei Huang, MD 1, Gan Huang, MD 2, Ying Ji, MD 3, Rong guang Ao, MD 3, Baoqing Yu, MD 4, Ya long Zhu, MD 3 1
Postgraduate Student, Shanghai Medical College, Fudan University, Shanghai, China Surgeon, Department of Orthopaedics, Changhai Hospital, The Second Military Medical University, Shanghai, China Surgeon, Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, Shanghai, China 4 Professor, Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, Shanghai, China 2 3
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Achilles tendon rupture is a common injury, especially in those who are physically active. Although open surgery is a widely used option for the treatment of acute Achilles tendon rupture, the optimal treatment is still disputed. In our study, 59 patients with unilateral, closed, acute rupture of the Achilles tendon were treated by open surgery using an allograft weave to augment the repair. All the surgeries were performed within 1 to 4 days after injury. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was recorded as 91.20 (range 88 to 95), 95.34 (range 92 to 98), and 98.27 (range 97 to 99) at the 3-, 6-, and 12-month follow-up visit, respectively. At the final follow-up visit, the mean difference between the mid-calf circumference of the injured and uninjured legs was 0.19 (range 0.03 to 1.50) cm (p ¼ .43). At the final follow-up visit, the mean difference between the vertical distances from the plantar surface of the heel to the ground for the injured and uninjured lower extremities was 0.44 (range 0.03 to 0.5) cm (p ¼ .17). Augmented repair using the allograft tendon weaving technique provided satisfactory tendon strength and functional outcomes and a timely return to the patients’ activities. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle clinical outcome injury surgery
Rupture of the Achilles tendon is not rare, especially in active middle-age men, who account for approximately 35% of all Achilles tendon injuries (1), most of which are sports-related (2). The treatment options for acute Achilles tendon rupture include conservative therapy and percutaneous or open surgical repair. However, the optimal treatment remains controversial, and each of these 3 options has its inherent advantages and disadvantages (3–5). Conservative treatment has been recommended in some studies. According to a follow-up questionnaire of 487 patients, conservative treatment was regarded as the preferable option for most patients because of its relatively low incidence of repeat rupture and other complications and the good Achilles tendon total rupture scores (6). Taking postoperative rehabilitation protocols into consideration, a meta-analysis of randomized trials showed that conservative Financial Disclosure: This study was funded by the Outstanding Leaders Training Program of Pudong Health Bureau of Shanghai (grant PWR12013-01). Conflict of Interest: None reported. Drs X. Huang and G. Huang are first coauthors. Address correspondence to: Baoqing Yu, MD, Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, No. 2800, Gongwei Road, Huinan Town, Pudong New Area, Shanghai 201301, China. E-mail address: [email protected] (B. Yu).
treatment was preferable at centers equipped with functional rehabilitation facilities (7). In contrast, at centers at which range-of-motion protocols are not available, surgical repair should be considered because of its lower incidence of repeat rupture (7). However, the longer period of immobilization required for nonoperative treatment, compared with open surgery, reduces the tonicity of the Achilles tendon (8) and has been associated with relatively greater rates of repeat rupture (9), drawbacks that limit the use of nonoperative management. Ma and Griffith (10) described percutaneous, or minimally invasive, repair of the ruptured Achilles tendon in 1977. With such techniques, the postoperative cosmetic appearance is significantly improved owing to the smaller incisions, which prevent full exposure of the ruptured tendon ends, but minimize surgical disruption of the paratendinous tissues (9,10). Nevertheless, sural nerve entrapment and inadequate apposition of the tendon ends have been associated with percutaneous methods because of the lack of adequate exposure and direct visualization of the surgical field (11,12). Open surgery has seemed to be preferred by most surgeons for the treatment of Achilles tendon rupture, because it permits anatomic restoration of the tendon length and minimizes compromise of the tendon’s tensile strength, especially in young active patients (5,7,9). The prevalent techniques for open surgery have included variations on primary end-to-end
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.12.029
2
X. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 1. Preoperative T2-weighted magnetic resonance imaging scan.
reapproximation of the proximal and distal ends of the Achilles tendon, such as the Krackow and Lindholm techniques (2). Augmentation of primary end-to-end reapproximation, such as the Teuffer technique (2), has also been described. Augmentation will strengthen the mechanical properties of the repaired Achilles tendon, making earlier and more aggressive rehabilitation protocols possible, reducing the risk of calf atrophy, repeat rupture, and limited ankle motion. In the present report, we evaluated the clinical and functional outcomes of 59 patients who had experienced acute, closed Achilles tendon rupture treated using open surgical reapproximation augmented with an allograft tendon weaving technique. Patients and Methods The inclusion criteria for the present study were a diagnosis of acute Achilles tendon rupture preoperatively and the receipt of open surgery using the allograft tendon weaving technique to augment the surgical reconstruction. Patients with diabetes, autoimmune disorders, complications of the ipsilateral lower limb fracture or neurovascular injury, and repeat Achilles tendon ruptures were excluded. The diagnostic criteria for Achilles tendon rupture consisted of the clinical presence of a palpable gap in the tendon, a positive Thompson test result (13), and magnetic resonance imaging evidence showing the ruptured tendon (Figs. 1 and 2). All ruptures were acute and unilateral. From February 2011 to April 2013, 1 of us (G.H.) searched the medical records of 124 patients who had been diagnosed with “acute Achilles tendon rupture” and found 59 patients fulfilling the criteria, including 6 females (10.17%) and 53 males (89.83%), with an mean age of 36.2 (range 18 to 51) years, as shown in Table 1. All the patients came from the practice of 1 of us (B.Y.). All the surgeries were performed within 1 to 4 days after the acute injury and were performed by 1 of us (B.Y.). In 54 patients (91.53%), the injury occurred in the practice of sports, and in 5 (8.48%), the rupture had resulted from a fall from a height. After admission to the hospital, all the patients received symptomatic treatment, including a short-leg cast to temporarily immobilize the affected limb and underwent magnetic resonance imaging to thoroughly evaluate the extent of the tendon damage. The specific site of the rupture was 3 to 6 cm proximal to the tendon’s insertion into the calcaneus in all 59 patients. One of us (G.H.) abstracted the data from the medical records to select the patients for the
Fig. 2. Preoperative T1-weighted magnetic resonance imaging scan.
investigation; 3 of us (Y.Z., R.O., Y.J.) assessed the patients’ outcomes; 1 of us (B.Y.) performed the surgeries; and 1 of us (X.H.) analyzed the data and wrote the report. In an attempt to limit biases, however, those of us who were not involved in the surgeries conducted the follow-up assessments. Surgical Procedure With the patient prone and under lumbar spinal or continuous epidural anesthesia, with a tourniquet applied to the ipsilateral thigh, routine disinfection of the surgical field and the contralateral limb was undertaken. The contralateral lower extremity was prepared to compare the tension in the Achilles tendon on both sides
Table 1 Patient characteristics (N ¼ 59 patients) Characteristic Sex Male Female Cause of injury Sports-related Falling down Duration of surgery (min) Mean Range Interval to recovery (wk) Mean Range Follow-up duration (y) Mean Range Intraoperative blood loss (mL) Mean Range Data presented as n (%), unless otherwise noted.
Value 53 (89.83) 6 (10.17) 54 (91.53) 5 (8.47) 42 35 to 80 11.2 11 to 15 2.1 1 to 3 26.30 20 to 30
X. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 4. Absorbent sutures were used to secure the allograft tendon where the graft was inserted through the tendon.
Fig. 3. Horsetail-like rupture 5 cm above the tendon insertion into the calcaneus in a 35year-old male patient with a sports-related injury.
during surgery. With the ipsilateral knee held in 30 flexion and ipsilateral foot in 10 plantar flexion at the ankle, the proximal and distal ends of the tendon were initially reapproximated, and suture tension was reduced when suturing the ruptured tendon. Making a posterior longitudinal incision parallel to the lateral border of the Achilles tendon, the skin, subcutaneous fat, and superficial fascia and paratenon layers were dissected layer by layer, with care taken not to compromise the sural nerve. Attention was given to maintain the aponeurosis as intact as possible when the nonviable portions of the tendon were debrided and the surrounding adhesions released. The ruptured tendon ends displayed a horsetail appearance in most cases (Fig. 3), which was irregular and ragged, and this is one of the reasons a full, extensile exposure can be very useful, because it enables the surgeon to fully inspect and reorganize the tendon ends. The proximal and distal ruptured ends were shaped into a regular configuration to enable homogenous distribution of tension across the reconstruction. The tendon ends were initially reapproximated with interrupted, 3-0, absorbable sutures crisscrossed within the body of the proximal and distal segments of the tendon. A long flexor allograft tendon, with the length ranging from 20 to 28 cm, was inserted through the distal segment of the tendon approximately 1 cm proximal to the insertion into the calcaneus and reinforced with 3-0 absorbable sutures in an interrupted fashion in the insertion sites (Fig. 4). The length of the allograft tendon used to reinforce the end-to-end reapproximation of the Achilles tendon depended on the size of the ruptured Achilles tendon. After the allograft was secured in the distal segment of the tendon, it was woven in a shoelace pattern through the proximal portion of the distal segment of the tendon, across the rupture interface, and then in a shoelace fashion from distally to proximally in the proximal portion of the Achilles tendon (Fig. 5) (14). The allograft weave should cross the rupture site at least once and should be secured in the proximal segment with the same interrupted sutures that were used in the distal segment. On completion of the weave, the proximal and distal ends of the Achilles tendon were secured at the proper physiologic tension (determined by comparison with the contralateral, uninjured lower extremity) using a
modified Krackow suture (2) of 2-0 with nonabsorbable suture (Fig. 6). Thereafter, anatomic layer closure proceeded from the paratenon to the superficial fascia and subcutaneous fat to the dermis, and a sterile bandage and short-leg plaster cast were used to immobilize the injured foot and ankle in a neutral position. A window was also left in the cast for dressing changes. The patients’ postoperative care entailed suture removal at the end of the second postoperative week, with the plaster cast removed at 4 weeks postoperatively and exercises for strength, range of motion, and proprioception initiated. At the end of the sixth postoperative week, the patients were allowed to walk with partial weightbearing facilitated by the use of crutches. Finally, patients were encouraged to undertake full weightbearing after 8 weeks of postoperative care.
Follow-Up Examinations The mean follow-up duration was 2.2 (range 1 to 3) years. During the follow-up period, the interval needed to return to the preinjury activity levels was recorded, and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score (15,16) was recorded at 3, 6, and 12 months after surgery. The results were graded as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor (
