Biomechanical Comparison of Tape Versus Suture in Simulated Achilles Tendon Midsubstance Rupture.

As sutures have progressed in strength, increasing evidence supports the suture tendon interface as the site where most tendon repairs fail. We hypothesized that suture tape would have a higher load to failure versus polyblend suture due to its larger surface area. Eleven matched pairs of cadaveric Achilles tendons were sutured with 2 mm wide braided ultrahigh molecular weight polyethylene tape (Tape) or 2 mm wide braided ultrahigh molecular weight polyethylene suture (Suture) using a Krackow repair method. All Achilles repair constructs were cyclically loaded, after which they were loaded to failure. Change in suture footprint height, clinical and ultimate load to failure, and location of failure was recorded. Clinical loads to failure for Tape and Suture were 290.4 ± 74.8 and 231.7 ± 70.4 Newtons, respectively (p= .01). Ultimate loads to failure for Tape and Suture were 352.9 ± 108.1 and 289.8 ± 53.7 Newtons, respectively (p = .11). Cyclic testing resulted in significant changes in footprint height for both Tape and Suture, but the 2 sutures did not differ in terms of the magnitude of change in footprint height (p = .52). The suture tendon interface was the most common site of failure for both Tape and Suture. Our results suggest that Tape may provide added repair strength in vivo for Achilles midsubstance rupture.

Plantar Fascia Release Through a Single Lateral Incision in the Operative Management of a Cavovarus Foot: A Cadaver Model Analysis of the Operative Technique.

Plantar fascia release and calcaneal slide osteotomy are often components of the surgical management for cavovarus deformities of the foot. In this setting, plantar fascia release has traditionally been performed through an incision over the medial calcaneal tuberosity, and the calcaneal osteotomy through a lateral incision. Two separate incisions can potentially increase the operative time and morbidity. The purpose of the present study was threefold: to describe the operative technique, use cadaveric dissection to analyze whether a full release of the plantar fascia was possible through the lateral incision, and examine the proximity of the medial neurovascular structures to both the plantar fascia release and calcaneal slide osteotomy when performed together. In our cadaveric dissections, we found that full release of the plantar fascia is possible through the lateral incision with no obvious damage to the medial neurovascular structures. We also found that the calcaneal branch of the tibial nerve reliably crossed the osteotomy in all specimens. We have concluded that both the plantar fascia release and the calcaneal osteotomy can be safely performed through a lateral incision, if care is taken when completing the calcaneal osteotomy to ensure that the medial neurovascular structures remain uninjured.

Factors Predicting Length of Hospital Stay and Extended Care Facility Admission After Hindfoot Arthrodesis Procedures.

Delayed identification of patients requiring admission to extended care facilities (ECFs) can lead to greater healthcare costs through an increased length of hospital stay (LOHS). Previous studies of hip and knee arthroplasty identified factors associated with a likely discharge to an ECF. These issues have not been extensively studied for major hindfoot procedures. We conducted a retrospective review of 198 cases treated during a 3-year period to identify the risk factors for an extended LOHS and ECF admission after ankle arthrodesis, triple arthrodesis, pantalar arthrodesis, and subtalar arthrodesis. The primary outcomes were LOHS and ECF admission. The independent predictors included age, sex, body mass index, housing status, American Society of Anesthesiologists class, diabetes and/or diabetic neuropathy, health insurance, fixation type, and perioperative infection. Stepwise multiple regression analysis was used to determine which variables were related to a longer LOHS. Nonparametric discriminant function analysis was used to identify the preoperative factors that best predicted ECF admission. A longer LOHS was significantly related to postoperative ECF admission, Centers for Medicare and Medicaid Services (CMS) insurance, diabetic neuropathy, external fixation, and infection. ECF admission was required for 34 of 198 patients (17.2%). Discriminant analysis found that older age, living alone, external fixation, and CMS insurance predicted a greater probability of ECF admission. The function accurately classified 94% of ECF admissions and 80% of non-ECF admission patients. ECF admission and CMS insurance extended the LOHS, likely owing to the administrative process of arranging an ECF discharge. If externally validated, the function we have derived could provide preoperative identification of likely ECF discharge candidates and reduce costs by shortening the LOHS.

Hospital-Based Acute Care After Total Hip and Knee Arthroplasty: Implications for Quality Measurement.

BACKGROUND: Although hospital readmissions are being adopted as a quality measure after total hip or knee arthroplasty, they may fail accurately capture the patient's postdischarge experience. METHODS: We studied 272,853 discharges from 517 hospitals to determine hospital emergency department (ED) visit and readmission rates. RESULTS: The hospital-level, 30-day, risk-standardized ED visit (median = 5.6% [2.4%-13.7%]) and hospital readmission (5.0% [2.6%-9.2%]) rates were similar and varied widely. A hospital's risk-standardized ED visit rate did not correlate with its readmission rate (r = -0.03, P = .50). If ED visits were included in a broader "readmission" measure, 246 (47.6%) hospitals would change perceived performance groups. CONCLUSION: Including ED visits in a broader, hospital-based, acute care measure may be warranted to better describe postdischarge health care utilization.

Anthropomorphic Characterization of Ankle Joint.

Even though total ankle replacement has emerged as an alternative treatment to arthrodesis, the long-term clinical results are unsatisfactory. Proper design of the ankle device is required to achieve successful arthroplasty results. Therefore, a quantitative knowledge of the ankle joint is necessary. In this pilot study, imaging data of 22 subjects (with both females and males and across three age groups) was used to measure the morphological parameters of the ankle joint. A total of 40 measurements were collected by creating sections in the sagittal and coronal planes for the tibia and talus. Statistical analyses were performed to compare genders, age groups, and image acquisition techniques used to generate 3D models. About 13 measurements derived for parameters (TiAL, SRTi, TaAL, SRTa, TiW, TaW, and TTL) that are very critical for the implant design showed significant differences (p-value < 0.05) between males and females. Young adults showed a significant difference (p-value < 0.05) compared to adults for 15 measurements related to critical tibial and talus parameters (TiAL, TiW, TML, TaAL, SRTa, TaW, and TTL), but no significant differences were observed between young adults and older adults, and between adults and older adults for most of the parameters. A positive correlation (r > 0.70) was observed between tibial and talar width values and between the sagittal radius values. When compared with morphological parameters obtained in this study, the sizes of current total ankle replacement devices can only fit a very limited group of people in this study. This pilot study contributes to the comprehensive understanding of the effects of gender and age group on ankle joint morphology and the relationship between tibial and talus parameters that can be used to plan and design ankle devices.

Implementation of a Multidisciplinary Preoperative Protocol for Geriatric Hip Fractures Improves Time to Surgery at a Level III Trauma Center.

Introduction: Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center. Materials and Methods: In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing. Results: There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001). Discussion: In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2. Conclusion: A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.

Inter- and intraobserver reliability in the radiographic evaluation of adult flatfoot deformity.

BACKGROUND: Adult acquired flatfoot is a complex deformity with numerous radiographic measurements described to define it. The purpose of this study was to evaluate the inter- and intraobserver reliability of six radiographic measurements using digital and conventional radiographs. MATERIALS AND METHODS: Three digital weightbearing radiographs consisting of anteroposterior, lateral, and hindfoot alignment views were obtained at presentation for 20 consecutive patients. Six radiographic measurements were made for each patient: talus/second metatarsal angle, calcaneal pitch angle, talus/first metatarsal angle, medial cuneiform/fifth metatarsal distance, tibial/calcaneal displacement, and calcaneal angulation. Each radiograph was evaluated on multiple occasions by a senior orthopaedic surgery resident, a junior orthopaedic surgery resident, and a third-year medical student. Inter- and intraobserver reliability was determined using measurements made on digital radiographs. RESULTS: Interobserver reliabilities were 0.830 for talus/second metatarsal angle, 0.948 for calcaneal pitch angle, 0.781 for talus/first metatarsal angle, 0.991 for medial cuneiform/fifth metatarsal distance, 0.870 for tibial/calcaneal displacement, and 0.834 for calcaneal angulation. Interobserver reliability was similar for digital and conventional radiographs, and intraobserver reliability increased with observer experience. CONCLUSION: Adult acquired flatfoot deformity is a complex condition that is difficult to quantify radiographically. The medial cuneiform/fifth metatarsal distance and the calcaneal pitch angle were found to have the highest interobserver reliability. Intraobserver reliability increased with observer experience.

The Popularity of Outcome Measures Used in the Foot and Ankle Literature.

Background. Outcome measures are frequently employed in clinical studies to determine the efficacy of orthopaedic surgical procedures. However, substantial variability exists among the outcome instruments utilized in foot and ankle (F&A) literature. The purpose of this study is to determine the number of outcome measures reported in F&A literature recently published in major orthopaedic journals and the association between study characteristics and the use of particular outcome measurement categories. Methods. All manuscripts published in 6 major orthopaedic journals between 2013-2017 reporting at least one clinical outcome measure were collected. For each manuscript, the journal, title, authors, country/region of origin, level of evidence, topic, and anatomic location were recorded. Outcome measures were characterized as generic, F&A specific, and disease specific. Poisson regression with robust error variance was used to test for association between study characteristics and outcome measure categories. Results. A total of 541 F&A articles were included with fifty-two different outcome measures reported. The most popular tool was the American Orthopaedic Foot and Ankle Score (AOFAS) (56.9%). Generic outcome measures were used in 331 (61.1%) studies, while 440 (81.3%) studies used F&A specific measures and 64 (11.8%) used disease-specific measures. The use of generic and disease-specific outcome measures was associated with a higher level of evidence (p < 0.001). Conclusion. AA substantial variety of outcome measures are employed among recent published studies, with many studies utilizing non-validated measures. Reporting a combination of validated and focused outcome measures is necessary to improve the quality and generalizability of published studies in foot and ankle literature. Levels of Evidence: Level II: Systematic review.

Effect of Opioid Limiting Legislation on Postoperative Opioid Utilization in Patients Treated for Ankle Fractures.

BACKGROUND: The state of Ohio implemented legislation in August of 2017 limiting the quantity of opioids a provider could prescribe. The purpose of this study was to identify if implementation of legislation affected opioid and nonopioid utilization in patients operatively treated for ankle fractures in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage. METHODS: A retrospective review of 144 patients treated for isolated ankle fractures in a pre-law group (January 2017-July 2017; n = 73) and post-law group (January 2018-July 2018; n = 71) was completed using electronic medical records and a legal prescriber database. Total number of opioid prescriptions, pills, milligrams of morphine equivalents (MMEs), and nonopioid prescriptions were recorded. Multiple regression analysis was run to identify predictors of opioid prescribing after controlling for law group, demographic, preoperative narcotic use, and injury severity characteristics. RESULTS: Mean MME prescribed per patient significantly decreased from 817.2 MME pre-law to 380.9 post-law (P < .01). Mean number of opioid pills prescribed per patient decreased from 99.1 in the pre-law group and 55.3 in the post law group (P < .001), respectively. Multiple linear regression analysis to predict the mean number of opioid pills prescribed was statistically significant (R 2 = 0.33; P < .001), with law group adding significantly to the prediction (P < .001). The multiple linear regression analysis to predict MME per patient was found to be statistically significant (R 2 = 0.31; P < .001), with the law group contributing significantly (P < .001). CONCLUSION: The Ohio prescriber law successfully contributed to the decreased number of opioid pills and MME prescribed in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage. Policies on opioid prescriptions may serve as an important public health tool in the fight against the opioid epidemic. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Improvement and Retention of Arthroscopic Skills in Novice Subjects Using Fundamentals of Arthroscopic Surgery Training (FAST) Module.

INTRODUCTION: Analysis of the Fundamentals of Arthroscopy Surgery Training (FAST) workstation regarding increased proficiency and retention of basic arthroscopy skills in novice subjects. METHODS: First-year medical students from a single allopathic medical school performed weekly standardized FAST workstation modules for a consecutive 6 weeks. Primary outcomes evaluated were time to task completion and error rate on specific modules. Scores were analyzed using a one-way repeated measures analysis of variance design for overall trends in time and errors over the 6-week study. Psychomotor retention was analyzed after a 12-week and 24-week interlude. RESULTS: Across the initial 6-week study, the average time to complete all modules at the workstation decreased significantly (P < 0.001) with a mean reduction in the total workstation time of 21.9 minutes (s = 8.12 minutes). Weekly comparisons showed the most significant improvement from week 1 to week 2 for the total workstation time (P < 0.001). Results after a 12-week and 24-week interval of inactivity demonstrated no significant difference in the mean workstation time or errors when compared with the original 6-week study. DISCUSSION: The FAST workstation significantly improved the task performance of novice participants over a 6-week period with no significant deterioration in task performance after 12 and 24 weeks of inactivity.

Fatty infiltration of the gastrocsoleus after tendo-achilles lengthening and gastrocnemius recession in a rabbit model.

BACKGROUND: Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are components of the operative treatment for certain foot conditions. We investigated changes in rabbit gastrocsoleus weight, volume, and percent fat resulting from TAL, GR, and immobilization. MATERIALS AND METHODS: Eighteen rabbits were randomized into three groups. Group I = gastrocnemius recession; Group II = (TAL) Z-plasty lengthening; Group III = immobilization only. Treatment limbs were randomized. Six randomly selected contralateral limbs were used for controls. At 12 weeks the gastrocnemius and soleus were weighed (g) and measured (ml) separately. Values were combined and analyzed as a gastrocsoleus complex. The weight, volume, and percentage of fatty infiltration were analyzed using one-way analysis of variance (ANOVA). RESULTS: The following differences were statistically significant. GR volume was less than control (p < 0.01); TAL weight and volume was less than control (p < 0.01); GR percent fat was greater than control (p < 0.05) and TAL percent fat was greater than control (p < 0.05). GR weight and volume was less than cast only (p < 0.01); TAL weight and volume was less than cast only (p < 0.01); TAL percent fat was greater than cast only (p < 0.01); GR percent fat was greater than cast only (p < 0.05); GR weight was greater than TAL (p < 0.05). CONCLUSION: In a rabbit model, the findings suggest the gastrocsoleus undergoes atrophy and fatty infiltration after TAL or GR. Immobilization does not contribute to either process. CLINICAL RELEVANCE: These findings correlate with human functional studies documenting the relationship between TAL or GR and decrease in plantarflexion strength. Further studies are needed to determine if significant variation in functional differences due to TAL versus GR exists.

Patterns in Opioid Prescription for Patients Operatively Treated for Ankle Fractures Following Implementation of 2017 Ohio Opioid Prescriber Law.

BACKGROUND: The purpose of this study was to report patterns of opioid prescription for patients treated operatively for ankle fractures after implementation of the 2017 Ohio Opioid Prescriber Law in comparison to the previous year. METHODS: A total of 144 patients operatively treated for isolated ankle fractures during two 6-month periods, January 2017 to July 2017 (pre-law) and January 2018 to July 2018 (post-law), were retrospectively identified. Preoperative and postoperative patient narcotic use was reviewed using a legal prescriber database. Total number of prescriptions, quantity of pills, and morphine milligram equivalents (MMEs) per patient prescribed during the 90-day postoperative period were compared between those treated before and those treated after implementation of the Ohio prescriber law. RESULTS: The average number of opioid prescriptions prescribed per patient in the 90-day postoperative period was 2.3 in the pre-law group and 2.1 in the post-law group (P = .625). The average MMEs prescribed per patient dropped from 942.4 MME pre-law to 700.5 MME post-law (P = .295). Differences in the average number of pills per prescription pre- and post-law (49.7 vs 36.2) and average MME per prescription (382.1 mg vs 275.2 mg) were statistically significant (P < .001 and P = .016, respectively). CONCLUSION: Following the implementation of the 2017 Ohio Opioid Prescriber Law, there was a downward trend in the number of pills per prescription and MMEs per prescription in patients operatively treated for isolated ankle fractures. The presence of a downward trend in the quantity of opioids prescribed in this patient cohort suggests the effectiveness of the state law. LEVEL OF EVIDENCE: Level III, comparative study.

Calcaneal avulsion fractures: complications from delayed treatment.

Calcaneal fractures represent approximately 2% of all fractures, of which 25% to 40% are classified as extra-articular in nature. Most calcaneal fractures are closed injuries that are treated nonoperatively, or if treated operatively, surgery is delayed to allow subsidence of swelling. The purpose of this article is to highlight a subset of calcaneal fractures that should be addressed urgently. Calcaneal tuberosity avulsion fractures often compromise the thin posterior skin that covers the insertion of the Achilles tendon. These patients are at risk for skin breakdown of the posterior heel and tissue necrosis if they do not receive urgent treatment. This case series presents 3 posterior tuberosity calcaneal avulsion fractures that led to skin necrosis because of a delay in treatment.

Simultaneous bilateral hip fractures in a level I trauma center.

BACKGROUND: Hip fractures are a common occurrence among the population today, especially in the elderly. However, the incidence of simultaneous bilateral hip fractures is very rare, and there is a paucity of data in the current literature documenting patients with these hip fractures. METHODS: A retrospective case review was performed on all patients treated for hip fractures during the past ten years at our Level I trauma center. RESULTS: From 1993 to 2002 there were eight patients who sustained simultaneous bilateral hip fractures. The mean age of the patients was 63 years (range, 34-88 years). The overall survival rate was 63%. In the patients of age group younger than 65, the survival rate was three out of four (75%). In the patients of age group 65 and older, the survival rate was two of four (50%). The length of hospital stay was shorter on average for the younger population, 19 days (range, 17-27 days). The average hospital duration for the older population was 29 days (range, 28-30). CONCLUSION: Bilateral hip fractures are usually the result of a high-energy trauma and are associated with other injuries. The morbidity and mortality of this injury are quite high. Patient age, associated injuries, and comorbid conditions should be examined closely because they may influence the patient's recovery.

Use of an acellular regenerative tissue matrix in combination with vacuum-assisted closure therapy for treatment of a diabetic foot wound.

UNLABELLED: Diabetic foot ulcers can be difficult to treat for a variety of reasons, and may result in amputation. The use of skin grafts can often be a useful method of achieving wound coverage and subsequent healing of diabetic foot ulcers; however, this method of treatment requires creation of a donor site wound that adds to the patient's overall wound burden. Application of an acellular regenerative tissue matrix may eliminate the need for harvesting a skin graft in order to cover a nonhealing wound. The use of vacuum-assisted wound closure has been shown to promote an environment that enhances wound bed contraction and surface epithelialization. The combination of an acellular regenerative tissue matrix with vacuum-assisted wound closure can be used to promote healing in the management of a nonhealing diabetic foot wound. LEVEL OF CLINICAL EVIDENCE: x.

Update on Misrepresentation of Research Publications Among Orthopaedic Surgery Residency Applicants.

BACKGROUND: Our 2 previous studies (1999, 2007) examining misrepresentation of research publications among orthopaedic residency applicants revealed rates of misrepresentation of 18.0% and 20.6%, respectively. As the residency selection process has become more competitive, the number of applicants who list publications has increased. The purpose of this study was to determine current rates of research misrepresentation by orthopaedic surgery applicants. METHODS: We reviewed the publication listings and research section of the Common Application Form from the Electronic Residency Application Service (ERAS) for all applicants applying to 1 orthopaedic residency program. The PubMed-MEDLINE database was principally used to search for citations. The PubMed Identifier (PMID) number was used; if no PMID number was listed, a combination of authors or the title of the work was used. If the citations were not found through PubMed, a previously developed algorithm was followed to determine misrepresentation. Misrepresentation was defined as (1) nonauthorship of a published article in which authorship was claimed, (2) claimed authorship of a nonexistent article, or (3) self-promotion to a higher authorship status within a published article. RESULTS: Five hundred and seventy-three applicants applied to our institution for residency in 2016 to 2017: 250 (43.6%) of 573 applicants did not list a publication, whereas 323 (56.4%) of 573 applicants listed ≥1 publication. We found 13 cases of misrepresentation among a total of 1,100 citations (1.18% in 2017 versus 18.0% in 1999 and 20.6% in 2007, p < 0.001). Ten cases of misrepresentation were self-promotion to a higher authorship status. There were 2 cases of claimed authorship of an article that could not be found. Only 1 applicant misrepresented more than once. CONCLUSIONS: Based on our findings, orthopaedic surgery residency applicants are accurately representing their publication information. The incorporation of the PMID number on the ERAS application has streamlined the process for finding publications, and has possibly encouraged veracity on residency applications. Faculty involved in the resident selection process should be aware of the significant decline in the rate of misrepresentation by medical students applying for orthopaedic surgery residency versus the rate in our prior studies.

Follow-up on misrepresentation of research activity by orthopaedic residency applicants: has anything changed?

BACKGROUND: In our previous study, published in 1999, we showed that 18% of research citations listed as published by orthopaedic residency applicants were misrepresented. Since our last report, we sought to determine whether there had been any change in the behavior of applicants wishing to pursue the field of orthopaedic surgery. METHODS: We evaluated the research citations that were identified after a review of the Publications section of the Common Application Form from the Electronic Residency Application Service for all applicants to our orthopaedic residency program for 2005 and 2006. Inclusion and exclusion criteria were established for citations listed on candidate applications. Citations were required to be from journals listed in Ulrich's Periodicals Directory. The PubMed-MEDLINE database engine was used to search for citations. If searching failed to yield the cited publication, a review of the journal of alleged publication was undertaken and an interlibrary search was conducted with the use of several research databases. When no match was found, the citation was labeled as misrepresented. Misrepresentation was defined as either (1) nonauthorship of an existing article or (2) claimed authorship of a nonexistent article. RESULTS: One hundred and forty-two (35.9%) of 396 applicants during the 2005 and 2006 application periods listed publications. A total of 304 citations were claimed from these 142 applicants. Listings included articles that were in press or in print (thirty-four citations), articles in journals not found in Ulrich's Periodicals Directory (twenty-eight citations), book chapters (twenty-three citations), and articles recorded as having been submitted (eighty-eight citations). These 173 works were excluded from our analysis. One hundred and thirty-one citations were referenced as appearing in journals per our search criteria, and all were verified. Twenty-seven or 20.6% (95% confidence interval, 14.2% to 28.7%) of 131 citations were misrepresented. CONCLUSIONS: The prevalence of misrepresented research publications from orthopaedic surgery residency applicants increased modestly to 20.6% compared with that found in our original report (18%). As we recommended in our last report, we strongly urge residency programs to require applicants to submit reprints of their publications with their residency applications. Perhaps standardized guidelines should be developed to help to prevent misrepresentation through the Electronic Residency Application Service.

Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective.

More than 200,000 people in the United States are diagnosed annually with compartment syndrome. This condition is commonly established based on clinical parameters. Determining its presence, however, can be challenging in obtunded patients or those with an altered mental status. A delay in diagnosis and treatment of these injuries can result in significant morbidity. Surgical release of the enveloping fascia remains the acceptable standard treatment for compartment syndrome. This article reviews the evaluation and treatment of compartment syndrome.

Biomechanical Head-to-Head Comparison of 2 Sutures and the Giftbox Versus Bunnell Techniques for Midsubstance Achilles Tendon Ruptures.

BACKGROUND: Acute midsubstance Achilles tendon ruptures are a common orthopaedic problem for which the optimal repair technique and suture type remain controversial. Head-to-head comparisons of current fixation constructs are needed to establish which stitch/suture combination is most biomechanically favorable. HYPOTHESIS: Of the tested fixation constructs, Giftbox repairs with Fiberwire will exhibit superior stiffness and strength during biomechanical testing. STUDY DESIGN: Controlled laboratory study. METHODS: Two biomechanical trials were performed, isolating stitch technique and suture type, respectively. In trial 1, 12 transected fresh-frozen cadaveric Achilles tendon pairs were randomized to receive either the Giftbox-modified Krackow or the Bunnell stitch with No. 2 Fiberwire suture. Each repair underwent cyclic loading, oscillating between 10 and 100 N at 2 Hz for 1000 cycles, with repair gapping measured at 500 and 1000 cycles. Load-to-failure testing was then performed, and clinical and catastrophic failure values were recorded. In trial 2, 10 additional paired cadaveric Achilles tendons were randomized to receive a Giftbox repair with either No. 2 Fiberwire or No. 2 Ultrabraid. Testing and data collections protocols in trial 2 replicated those used in trial 1. RESULTS: In trial 1, the Bunnell group had 2 failures during cyclic loading while the Giftbox had no failures. The mean tendon gapping after cyclic loading was significantly lower in the Giftbox repairs (0.13 vs 2.29 mm, P = .02). Giftbox repairs were significantly stiffer than Bunnell (47.5 vs 38.7 N/mm, P = .019) and showed more tendon elongation (5.9 ± 0.8 vs 4.5 ± 1.0 mm, P = .012) after 1000 cycles. Mean clinical load to failure was significantly higher for Giftbox repairs (373 vs 285 N, P = .02), while no significant difference in catastrophic load to failure was observed (mean, 379 vs 336 N; P = .61). In trial 2, there were no failures during cyclic loading. The Giftbox + Fiberwire repairs recorded higher clinical load-to-failure values compared with Giftbox + Ultrabraid (mean, 361 vs 239 N; P = .005). No other biomechanical differences were observed in trial 2. CONCLUSION: Simulated early rehabilitation biomechanical testing showed that Giftbox-modified Krackow Achilles repair technique with Fiberwire suture was stronger and more resistant to gap formation at the repair site than combinations that incorporated the Bunnell stitch or Ultrabraid suture. CLINICAL RELEVANCE: A more in-depth understanding of the biomechanical properties of the Giftbox repair will help inform surgical decision making because stronger repairs are less likely to fail during accelerated postoperative rehabilitation.

Suture-Only Repair Versus Suture Anchor-Augmented Repair for Achilles Tendon Ruptures With a Short Distal Stump: A Biomechanical Comparison.

BACKGROUND: Chronic noninsertional Achilles tendinosis can result in an acute Achilles tendon rupture with a short distal stump. In such tendon ruptures, there is a limited amount of adequate tissue that can hold suture, thus presenting a challenge for surgeons who elect to treat the rupture operatively. HYPOTHESIS: Adding suture anchors to the repair construct may result in biomechanically stronger repairs compared with a suture-only technique. STUDY DESIGN: Controlled laboratory study. METHODS: Nine paired Achilles-calcaneus complexes were harvested from cadavers. An artificial Achilles rupture was created 2 cm proximal to the insertion on the calcaneus. One specimen from each cadaver was assigned to a suture-only or a suture anchor-augmented repair. The contralateral specimen of the same cadaver received the opposing repair. Cyclic testing was then performed at 10 to 100 N for 2000 cycles, and load-to-failure testing was performed at 0.2 mm/s. This was followed by analysis of repair displacement, gapping at repair site, peak load to failure, and failure mode. RESULTS: The suture anchor-augmented repair exhibited a 116% lower displacement compared with the suture-only repair (mean ± SD, 1.54 ± 1.13 vs 3.33 ± 1.47 mm, respectively; P < .03). The suture anchor-augmented repair also exhibited a 45% greater load to failure compared with the suture-only repair (303.50 ± 102.81 vs 209.09 ± 48.12 N, respectively; P < .04). CONCLUSION: Suture anchor-augmented repairs performed on acute Achilles tendon ruptures with a short distal stump are biomechanically stronger than suture-only repairs. CLINICAL RELEVANCE: Our results support the use of suture anchor-augmented repairs for a biomechanically stronger construct in Achilles tendon ruptures with a short distal stump. Biomechanically stronger repairs may lead to less tendon repair gapping and failure, increasing the ability to start early active rehabilitation protocols and thus improving patient outcomes.