The option of transosseous distal suture placement during minimally invasive Achilles tendon repair for high-risk patients can improve outcomes, however does not prevent re-rupture.

PURPOSE: Achilles tendon ruptures (ATRs) close to the insertion, in high-level athletes, and in patients at high risk of re-rupture, may be better suited to operative repair. Minimally Invasive Repair (MIR) of the Achilles tendon has excellent outcome and low complication rates. Traditionally MIR has showed lower repair strength, failing due to suture pull-out from the distal tendon stump. The aim of this study was to describe the outcome of ATR patients who received transosseous distal suture placement using a standard technique as a reference. METHODS: Following ATR, patients were evaluated for pre-injury activity level, body weight, location of the tear and size of the distal Achilles tendon stump. Patients considered to be at high-risk of re-rupture: Tegner level ≥ 8, body weight ≥ 105Kg and distal ATR, received transosseous (TO) distal suture placement (n = 20) rather than the usual transtendinous (TT) technique (n = 55). Patient reported outcome measures and functional evaluation was performed at 12 months following repair. RESULTS: At 12 months follow up both methods resulted in good median (IQR) Achilles tendon Total Rupture Score TO 83.8 (74-88.3) vs. TT 90 (79-94), low increased relative Achilles Tendon Resting Angle TO -3.5˚ (3.6) vs. TT -3.5˚ (3.3) and mean (SD) Single leg Heel-Rise Height Index TO 88.2% (9.9) vs. TT 85.6% (9.9) (n.s.). There were 4 re-ruptures in the high-risk group and 2 in the group receiving TT distal suture placement. All but one of these were traumatic in nature. The mode of failure following TO distal suture placement was proximal suture pull out. CONCLUSIONS: To distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients can lead to results equivalent to those in lower-risk patients treated with a standard TT MIR technique, except for the re-rupture rate which remained higher. There may be factors that have greater influence on outcome other than suture placement following ATR.

The ALR-RSI score can be used to evaluate psychological readiness to return to sport after acute Achilles tendon tear.

PURPOSE: The return to sport is one of the main goals following Achilles tendon tear repair. Several psychological factors influence the return to sport after a sports injury. The traditional tools to assess the return to sport do not take into account psychological factors. The ankle ligament reconstruction-return to sport injury (ALR-RSI), validated for ankle instability, is a score to evaluate psychological readiness to return to sport. The goal of this study was to validate the ALR-RSI score for the assessment of the readiness to return to sport after Achilles tendon repair. METHODS: The ALR-RSI score, adapted from the anterior cruciate ligament-return to sport injury (ACL-RSI) score used following knee ligament reconstruction, was validated according to the international COSMIN methodology. Patients operated for Achilles tendon repair responded to the questionnaire during the rehabilitation period. The EFAS, FAAM and VISA-A scores were used as reference questionnaires. RESULTS: A total of 50 patients were included. The ALR-RSI score was strongly (r > 0.5) correlated to the EFAS score: r = 0.68 [0.50-0.80] the FAMM sport score: r = 0.7 [0.52-0.84] the FAAM AVQ score (r = 0.6 [0.35-0.78]), and the VISA-A score (r = 0.54 [0.26-0.76]). The discriminant validity was good with the ALR-RSI, which was significantly lower in the patients that did not return to sport: 60.7 (40-81.4) compared to those that did: 83.2 (64.3-100) p = 0.001. Reproducibility was excellent with an intra-class correlation coefficient ρ of 0.99 [097-1.00]. The internal consistency was excellent (alpha coefficient = 0.95). CONCLUSION: The ALR-RSI score provides a valid, reproducible assessment of the psychological readiness to return to sport in patients who undergo surgical Achilles tendon suture repair. LEVEL OF EVIDENCE: III.

Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair.

Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.

Locating the danger zone to avoid injury to the sural nerve during Achilles calcaneal tendon repair. A systematic review of cadaveric studies with clinical implications.

INTRODUCTION: Although iatrogenic injuries to the sural nerve (SN) are commonly encountered in calcaneal (Achilles) tendon (CaT) repair surgeries, the relationship between both structures have anatomical variations. A quantitative evidence synthesis has not been yet conducted. Our systematic review aims to better define the safe zone where the SN crosses the lateral border of CaT. METHODS: Electronic databases were searched to locate relevant anatomical studies recording details regarding the distance at which SN crosses the CaT. The Checklist for Anatomical Reviews and Meta-Analyses (CARMA) was followed. The primary outcome was the mean distance from CaT insertion to SN crossing site, to locate a safe zone. The secondary outcome was the mean horizontal distance from the SN to the CaT lateral border. RESULTS: Seven studies met the inclusion criteria with a total of 204 cadaveric limbs. The danger zone was located 2 cm distal and proximal to the mean distance of the crossing point. The mean distance from CaT insertion to the SN crossing site was 9.91 ± 0.67 cm. The mean horizontal distance between SN and the CaT lateral border decreased from a mean of 19.8 ± 2.06 mm at the calcaneal tuberosity level to 3.6 ± 0.4 mm at 10 cm proximal to the tuberosity. DISCUSSION: This review demonstrated that 10 cm is the average distance from the CaT insertion onto the calcaneal tuberosity to the point of crossing of the SN. A safe zone would be 2 cm away proximally and distally from the crossing point. We recommend placing the proximal lateral sutures away from this region. This finding should help surgeons avoid SN injuries during open or percutaneous approaches for calcaneal tendon rupture.

A biomechanical comparison of Achilles tendon suture repair techniques: Locking Block Modified Krackow, Kessler, and Percutaneous Achilles Repair System with the early rehabilitation program in vitro bovine model.

BACKGROUND: The Krackow technique has the advantage of high strength, though it is not minimally invasive. The "Locking Block Modified Krackow" (LBMK) peri-tendon fixation technique was designed for minimally invasive surgery. This study aimed to compare the biomechanics of LBMK with Kessler and Percutaneous Achilles Repair System (PARS) techniques using a simulated early rehabilitation program. MATERIALS AND METHODS: Thirty-fresh bovine Achilles tendon specimens were randomly assigned to the LBMK, Kessler, and PARS groups (n = 10). In LBMK group, the main suture configuration was the LBMK technique, and the transverse suture was used as the secondary suture configuration. The Kessler group employed three suture configurations, two sagittal, one coronal plane. In the PARS group, two transverse and one locking sutures were placed at either end of the tendon. Each repaired specimen underwent two cyclic loading protocols (20-100 N, 20-190 N), 500 cycles, followed by measurement of the gap between the tendon ends. All specimens underwent a load-to-failure test at a 25 mm/s stretching rate. RESULTS: After the first loading cycle, the average gaps of the LBMK, Kessler and PARS groups were 0.76 ± 0.44 mm, 1.80 ± 0.82 mm, and 2.66 ± 1.04 mm, respectively. The LBMK group had a significantly reduced gap than the other groups (p < 0.01). The LBMK group gaps were all within 2 mm. The Kessler and PARS groups had six, and two specimens within 2 mm, respectively. After the second loading cycle, the average end gaps of the LBMK, Kessler, and PARS groups were 3.68 ± 1.08 mm, 5.70 ± 0.89 mm and 7.59 ± 1.26 mm, respectively. The LBMK group had a significantly reduced average gap than the other groups (p < 0.01). The maximum load-to-failure was highest 732.8 ± 138 N in the LBMK than the other groups (p < 0.01). CONCLUSION: The biomechanical strength of the LBMK suture was significantly greater than Kessler and PARS. The reduced gap in the LBMK group suggests superior resistance to gap formation, which may occur during early postoperative rehabilitation.

Evaluation of a New Knotless Suture Anchor Repair in Acute Achilles Tendon Ruptures: A Biomechanical Comparison of Three Techniques.

Acute ruptures of the Achilles tendon are a common injury, and debate has continued in published studies on how best to treat these injuries. Specifically, controversy exists regarding the surgical approaches for Achilles tendon repair when one considers percutaneous versus open repair. The present study investigated the biomechanical strength of 3 different techniques for Achilles tendon repair in a cadaveric model. A total of 36 specimens were divided into 3 groups, each of which received a different construct. The first group received a traditional Krackow suture repair, the second group was repaired using a jig-assisted percutaneous suture, and the third group received a repair using a jig-assisted percutaneous repair modified with suture anchors placed into the calcaneus. The specimens were tested with cyclical loading and to ultimate failure. Cyclical loading showed a trend toward a stronger repair with the use of suture anchors after 10 cycles (p = .295), 500 cycles (p = .120), and 1000 cycles (p = .040). The ultimate load to failure was greatest in the group repaired with the modified knotless technique using the suture anchors (p = .098). The results of the present study show a clear trend toward a stronger construct in Achilles repair using a knotless suture anchor technique, which might translate to a faster return to activity and be more resistant to an early and aggressive rehabilitation protocol. Further clinical studies are warranted to evaluate this technique in a patient population.

Comparative anatomical study of standard percutaneous and modified medialised percutaneous Bunnell type repair for artificial Achilles tendon rupture: positive effect of medialisation of the stitches with lower risk of sural nerve injury.

BACKGROUND: Less invasive percutaneous acute Achilles tendon rupture (AATR) repair techniques gain popularity because of lower risk of surgical wound complications. But these approaches have an increased risk of sural nerve iatrogenic injury as this sensory nerve is usually not visualised during minimally invasive operative procedures. We compared standard percutaneous Bunnell type and our proposed modified-medialised percutaneous technique in a cadaver study to evaluate potential advantages. MATERIALS AND METHODS: Ten pairs of fresh frozen specimens were divided into two groups for comparative anatomical study. Tenotomies of Achilles tendons were made and wounds sutured. Ten standard and 10 modified-medialised repairs were applied for artificially performed ruptures. All sutured tendons were dissected meticulously. We carefully looked at repaired Achilles tendon end-to-end contact and adaptation, distance from Achilles insertion in calcaneal tubercle to place where sural nerve crosses lateral border of the Achilles tendon and possible sural nerve and vein entrapment. Groups were compared using Fisher's exact and Student-T tests. RESULTS: All ends of sharply dissected tendons in both groups were in sufficient contact. No measurable diastasis between tendon ends was found in all cases. No entrapment of sural nerve or vein was found in modified percutaneous Bunnell suture technique group, whereas 7 of 10 sural nerves and 9 small saphenous veins were entrapped when using standard percutaneous Bunnell type technique. Average distance from Achilles tendon insertion in tuber calcanei to sural nerve crossing the lateral border of Achilles was 93 mm. CONCLUSIONS: Medialisation of percutaneous suture in AATR repair shows clear advantages compared to standard non medialised technique ensuring a possible lower incidence of sural nerve entrapment injury. Our modified percutaneous Bunnell type technique allows sufficient adaptation of ruptured Achilles tendon.

Auditing the Representation of Female Athletes in Sports Medicine Research: Achilles Repair.

Background: Establishing evidence-based recommendations specific to female athletes has been overlooked in sports medicine. Achilles tendon rupture is one of the most common musculoskeletal injuries, occurring in 15 to 55 per 100 000 people annually. Differences in injury rates could be due to hormonal effects, as estrogen receptors have been identified in tendons along with decreased tendon strain based on oral contraceptive use. The primary purpose of this study was to audit the representation of female athletes in the literature regarding Achilles repair. Methods: An electronic search was performed using PubMed to identify articles related to Achilles repair using the protocol by Smith et al. Studies were assessed by population, size, athletic caliber, study impact, research theme, and menstrual status. Results: Female representation across all studies was 1783 of 10 673 subjects (16.7%). Composition of included studies was predominantly mixed-sex cohorts with 131 of 169 (77.5%) included studies. Within mixed-sex cohort studies, the total representation of female athletes was 1654 of 8792 participants (18.9%). Thirty-two studies were male only, constituting 1540 participants, whereas 3 studies were female only composed of 86 athletes. Importantly, the disparity between male and female representation worsened as the athletic caliber of the study population increased, with 5.0% female representation in studies with professional athletes. No study collected data related to menstrual status and its potential relationship to Achilles rupture or postoperative outcomes. Conclusion: Mixed-sex cohort studies underrepresented female athletes, and male-only cohort studies were more common than female-only studies. These findings indicate a need for increased representation of female athletes as well as acknowledgment of menstrual status in research related to Achilles repair. Future studies should focus on representation of female athletes and data collection related to sex-specific hormones, hormonal contraceptive use, and menstrual status to improve treatment of Achilles tendon ruptures for female athletes. Level of Evidence: Level IV, case series.

Derivation and validation of a risk calculator for the prediction of incidence of complications following repair of Achilles Tendon Rupture.

BACKGROUND: The Achilles tendon is the body's strongest and largest tendon. It is commonly injured, particularly among athletes, accounting for a significant portion of serious tendon injuries. Several factors play a precipitating role in increasing the risk of these injuries. OBJECTIVE: Our objective is to derive and validate a risk calculator for the prediction of incidence of any complication following Achilles tendon repair. METHODS: We used de-identified data from the American College of Surgeons' National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2021. It comprises 7010 individuals who had undergone Achilles tendon rupture repair. Demographic and risk factors information was collected. To develop the calculator, the sample was divided into a derivation cohort (40%) and a validation cohort (60%). Multivariate logistic regression was used for statistical analysis, and a risk calculator for incidence of any complication was derived from the derivation cohort and validated on the remaining 60% of the sample. Patients with missing data were excluded, and the significance level was set at p < 0.05. RESULTS: We analyzed the derivation cohort of 2245 individuals who underwent Achilles tendon repair surgery between 2005 and 2021, with a 5.5% overall complication. Multivariate logistic regression identified anesthesia type, ASA classification, certain co-morbidities (pre-operative dialysis and medication-requiring hypertension), and wound classification as significant predictors of complications. The developed risk calculator model had an area under the curve (AUC) of 0.685 in the derivation cohort and 0.655 in the validation cohort, surpassing the widely used and validated modified frailty index. A cut-off score threshold of 0.06 was established using Youden's index to dichotomize individuals into low and high risk for developing any postoperative complications. CONCLUSION: Our risk calculator includes factors that most significantly affect the incidence of any complication following Achilles tendon repair.

Double-Row Achilles Insertional Repair With Rip-Stop Increases Construct Strength Compared to Traditional Techniques: A Biomechanical Study.

BACKGROUND: Although double-row suture-anchored (DRSA) techniques for Achilles insertional tendinosis has proven successful, a reoccurring failure mode not yet addressed is suture tearing through the tendon. This study aims to address suture tearing by incorporating a rip-stop element. Authors hypothesized that the Rip-Stop group would demonstrate increased strength compared with more traditional techniques. METHODS: 12 paired cadaveric feet were used in this study (n = 24). One sample from each pair was assigned to receive the standard double-row (SDR) Achilles repair with 4.75-mm knotless anchors (n = 12). The control's matched sides were divided between 2 DRSA bridge groups: modified double-row (MDR) bridge with 3.9-mm anchors or rip-stop double-row (RS-DR) bridge repair with soft proximal anchors and 3.9-mm anchored distal row. In neutral position, specimens underwent 1000 cycles (20-100 N) followed by load to failure. Displacements, stiffness, ultimate load, and failure mode were recorded. RESULTS: RS-DR had the lowest initial displacement values followed by SDR and MDR (1.3 ± 0.4, 2.7 ± 1.4, and 3.2 ± 1.3 mm, respectively). Significance was detected when comparing initial displacement of RS-DR to MDR (P = .038). Cyclic displacement was lowest for RS-DR, followed by MDR and SDR (1.6 ± 0.9, 2.2 ± 1.1, and 4.5 ± 3.2 mm, respectively). Cyclic stiffness was similar for RS-DR and MDR (89.1 ± 24.6 and 81.9 ± 5.6 N/mm, respectively). RS-DR ultimate load (1116.8 ± 405.7 N) was statistically greater than SDR (465.6 ± 352.7, P = .003). CONCLUSION: RS-DR-repaired specimens demonstrated a decrease in displacement values and increased ultimate load and stiffness when compared to other groups. Results of this cadaveric model suggest that the addition of a rip-stop to DRSA Achilles repair is more impactful than anchor size. Limitations include that this was a time-zero biomechanical study, which cannot simulate the performance of the repairs during postoperative healing and recovery. CLINICAL RELEVANCE: A rip-stop technique for Achilles repair effectively improves dynamic mechanical characteristics and may mitigate suture tearing through tendon in a patient cohort.

Surgical Management of Achilles Tendon Ruptures in the United States 2006-2020, an ABOS Part II Oral Examination Case List Database Study.

Background: In correlation with a growing body of evidence regarding nonoperative management for Achilles tendon rupture (ATR), studies from Europe and Canada have displayed a decreasing incidence in surgical management, which has not been noted in the United States. The primary objective of this study is to evaluate the US trend in ATR repair volume. Methods: The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination Case List Database was used. All cases using Current Procedural Terminology codes for primary ATR repair were requested from the years 2006-2020. Total submitted Achilles repair volume, the number of candidates submitting an Achilles repair case, and the overall submitted case volume per examination year was analyzed. Poisson and linear regressions were used to determine statistically significant trends. Results: The total number of Achilles repair cases submitted for the ABOS Part II Oral Examination significantly increased from 2006 to 2011 and then decreased until 2020. Taking Achilles repair cases as a proportion of total orthopaedic cases submitted, the same trend was seen. The number of candidates submitting an Achilles repair case increased from 2006 to 2009 and then decreased until 2020. Foot and Ankle fellowship-trained candidates submitted an increasing number of ATR repair cases per candidate during the time period studied. Conclusion: This is the first study to demonstrate a decline in the volume of ATR repair in the United States. The decline in ATR repair volume seen in the ABOS Part II Case Lists does not match previously published US surgeon practice patterns but is not necessarily generalizable to beyond this period. Although the overall ATR repair volume in the ABOS Part II Case Lists is decreasing, we found Foot and Ankle fellowship-trained surgeons are operating on an increasing number of ATRs during their board collection period. Level of Evidence: Level III, retrospective cohort study.

Achilles Tendon Repairs: Identification of Risk Factors for and Economic Impact of Complications and Reoperation.

BACKGROUND: Compared with nonoperative management, Achilles tendon repair is associated with increased rates of complications and increased initial healthcare cost. However, data are currently lacking on the risk factors for these complications and the added healthcare cost associated with common preoperative comorbidities. HYPOTHESIS: Identify the independent risk factors for complications and reoperation after acute Achilles tendon repair and calculate the added cost of care associated with having each preoperative risk factor. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: A retrospective review of a large commercial claims database was performed to identify patients who underwent primary operative management for Achilles tendon rupture between 2007 and 2016. The primary outcome measures of the study were risk factors for (1) postoperative complications, (2) revision surgery, and (3) increased healthcare resource utilization. RESULTS: A total of 50,279 patients were included. The overall complication rate was 2.7%. The most common 30-day complication was venous thromboembolism (1.2%). The rate of revision surgery was 2.5% at 30 days and 4.3% at 2 years. Independent risk factors for 30-day complications in our cohort included increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Independent risk factors for revision surgery within 2 years included female sex, tobacco use, hypertension, obesity, and the presence of any postoperative complication. The average 5-year cost of operative intervention was $17,307. The need for revision surgery had the largest effect on 5-year overall cost, increasing it by $6776.40. This was followed by the presence of a postoperative complication ($3780), female sex ($3207.70), and diabetes ($3105). CONCLUSION: Achilles tendon repair is a relatively low-risk operation. Factors associated with postoperative complications include increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Factors associated with the need for revision surgery include female sex, hypertension, obesity, and the presence of any postoperative complication. Female sex, diabetes, the presence of any complication, and the need for revision surgery had the largest added costs associated with them. CLINICAL RELEVANCE: Surgeons can use this information for preoperative decision-making and during the informed consent process.

Achilles: Failed Acute Repair.

Acute Achilles tendon ruptures are commonly managed with surgical repair. This particular surgery is prone to rerupture, wound complications, deep vein thrombosis, and sural nerve injuries. In this chapter the authors discuss complications, how to avoid them, and ultimately how to manage complications with your patients.

Safety and Efficacy of Achilles Repair Using the Mini-Open Approach in Supine Versus Prone Position: A Retrospective Study.

Purpose Surgical repair of the Achilles tendon is a common procedure in cases of acute rupture. Open Achilles tendon surgery with a traditional extensile approach is most often performed in the prone position, but this can lead to numerous complications. The mini-open approach for repair in the supine position may avoid the risks of the prone position. The purpose of this study is to compare perioperative outcomes and differences in cost between patients undergoing acute Achilles rupture repair with mini-open approach, incision of approximately 3 cm, in the supine position versus traditional approach in the prone position. Methods Patients who underwent surgical repair of acute Achilles rupture at a single institution were retrospectively identified using Current Procedural Terminology (CPT) code 27650. Complication rates and the total cost charged to the insurance companies of both the supine and prone groups were calculated. Results A total of 80 patients were included for analysis, 26 supine and 54 prone. The difference in average total time in the operating room was statistically significant. The prone position took approximately 15% more time (118.7 minutes) compared to the supine position (100 minutes) (p = 0.001). While not statistically significant, the total cost for the supine group ($19,889) was less than the for the prone group ($21,722) (p = 0.153) Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and deep vein thrombosis (DVT) rate were also similar between the two groups. No patient in either group experienced re-rupture of the Achilles tendon within the first year of primary repair. Conclusion The mini-open approach in the supine position may be advantageous in the repair of acute Achilles rupture in that it reduces total time in the operating room and total cost while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.

Heel Complications.

Postoperative complications can be burdensome on both the patient and the surgeon. Attention in literature is often directed toward different forms of treatment and successful outcomes in surgery. The incentive of this article is to bring insight toward postoperative complications in rearfoot surgery, more specifically, the repair of the Achilles tendon with suture tape and suture anchors. This article directs attention to the recent reports on hypersensitivity reactions seen with the use of suture tape and nonabsorbable suture anchors and may encourage physicians to make patients aware of this potential complication when using these materials.

Neglected Achilles Tendon Ruptures.

Achilles tendon ruptures are a common ailment and often missed in upwards of 25% of cases. Neglected Achilles injuries can be treated both conservatively and surgically. Physical therapy, bracing, and custom ankle-foot orthoses are some options to consider. Surgically, there are many options, depending on the quality of the existing tendon, size of the defect, and the surgeon's comfort with the technique. Those procedures include primary repair, V-Y tendon advancement, turndown flap, tendon transfers, and other allografts. These techniques have been shown to have good to excellent outcomes and typically return patients to activities without complaints.

Minimally Invasive Achilles Repair Techniques.

Achilles tendon rupture is an increasingly common problem with an aging population participating in high-level physical activities. Appropriate treatment has been debated for decades, but good outcomes have been reported after conservative and surgical management. The development of minimally invasive surgical techniques for Achilles repair has reduced the incidence of complications and maintained the high level of function reported after open surgery. The Achilles Midsubstance SpeedBridge repair is a newer minimally invasive technique that has demonstrated promising results and is the authors' preferred treatment of Achilles tendon rupture in athletes and active patients.

Minimally Invasive Treatments of Acute Achilles Tendon Ruptures.

Achilles tendon rupture is a common injury to the lower extremity that requires appropriate treatment to minimize functional deficit. Available treatments of Achilles tendon ruptures include nonoperative, open surgical repair, percutaneous repair, and minimally invasive repair. Open surgical repair obtains favorable functional outcomes with significant potential for deep soft tissue complications, calling into question the value of open repair. Percutaneous repair is an alternative option with comparable functional results and minimal soft tissue complications; however, sural nerve injury is a complication. Minimally invasive Achilles repair offers optimal results with superior functional outcomes with minimal soft tissue complications and sural nerve injury.

Open Reconstructive Strategies for Chronic Achilles Tendon Ruptures.

Chronic Achilles tendon ruptures typically are treated with surgical intervention except in low-demand patients or patients who are unable to tolerate surgery. Although several treatment strategies are described, most literature is case reports and case series. There is no widely accepted algorithm or gold standard for surgical treatment of chronic Achilles tendon ruptures. Treatment strategy depends on the size of the tendon gap after excision of nonviable tissue and scar tissue. Smaller gaps can be treated with direct end-to-end repair. Medium-sized gaps can be treated with tendon-lengthening procedures. Tendon transfers, autograft, allograft, xenograft, and synthetic grafting are described for the reconstruction of large defects.

Proximal and Distal Failure Site Analysis in Percutaneous Achilles Tendon Rupture Repair.

BACKGROUND: Different techniques have been described for percutaneous Achilles tendon rupture repair, but no biomechanical evaluation has been performed separately for proximal and distal suturing techniques. The purpose of this study was to biomechanically analyze proximal versus distal percutaneous Achilles suture configurations during cyclic loading and load to failure. METHODS: A simulated, midsubstance rupture was created 6 cm proximal to the calcaneal insertion in fresh-frozen cadaveric Achilles tendons. Fifteen proximal specimens were divided into 3 groups: (A1) triple locking technique, (A2) Bunnell-type technique, and (A3) double Bunnell-type technique. Twelve distal specimens were divided into 2 groups: (B1) triple nonlocking technique and (B2) oblique technique. Repairs were subjected to cyclic testing and load to failure. Load to failure, cause of failure, and tendon elongation were evaluated. RESULTS: None of the proximal specimens and 7/12 of the distal ones failed in cyclic testing. The proximal fixation groups demonstrated significantly more strength than the distal groups (P = .001), achieving up to 710 N of failure load in Group A3. Groups B1and B2 failed on average at 380 N with no difference between them (P > .05). The majority of all repairs failed in the suture-tendon interface. Distal groups had more elongation during cyclic testing (13.7 mm) than proximal groups (9.4 mm) (P = .02). CONCLUSION: The distal fixation site in this Achilles tendon repair was significantly weaker than the proximal fixation site. A proximal modified suture configuration increased resistance to cyclic loading and load to failure significantly. CLINICAL RELEVANCE: A modification can be suggested to improve strength of the Achilles repair.