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

Tian, Jian; Rui, Yongjun; Xu, Yang; Yang, Wengbo; Xu, Tonglong; Chen, Xueming; Zhang, Xingfei

doi:10.1007/s00402-020-03535-y

Cited by 14 publications

(9 citation statements)

References 22 publications

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“…56 Biomechanical studies suggest that AT strength following reconstruction may be reduced following percutaneous procedures. 51 Future studies should validate these results in using other AT repair strategies.…”

Section: Discussionmentioning

confidence: 83%

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture

et al. 2021

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Background: Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our “traditional” or a “slowed down” rehabilitation after percutaneous surgical repair. Methods: Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated. Results: At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one. Conclusion: Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study. Level of Evidence: Level II, prospective comparative study.

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Section: Discussionmentioning

confidence: 83%

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture

et al. 2021

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“…Differences in treatment specifics within groups may have further limited the validity of pooling studies to perform this analysis. Recent evidence has found that distinct surgical variations and variations in postoperative protocols result in different degrees of tendon elongation [8,18,27,30,40,72,86]. Further, post-treatment tendon elongation has been associated with lower patient-reported outcomes scores and reduced plantarflexion strength [28,79,91] Similarly, return to work and sport analyses were not performed because of very low evidence quality and poor assessment of the endpoints in question.…”

Section: Limitationsmentioning

confidence: 99%

What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Meulenkamp¹,

Woolnough

Cheng

et al. 2021

Clin Orthop Relat Res

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Background Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence. Questions/purposes We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery? Methods This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar. Results We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes. Conclusion Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations. Level of Evidence Level I, therapeutic study.

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“…Mainstream Achilles tendon suture techniques currently include Bunnell suture, Kessler suture, and Krackow suture, or ne-tuned techniques adapted to actual injuries based on various suture techniques [7][8][9][10]. The concept of rapid rehabilitation has become popular in recent years, and the reported tendon repair surgery has become more minimally invasive.…”

Section: Introductionmentioning

confidence: 99%

Clinical effect of three suture methods on acute Achilles tendon rupture under two types of incisions

You

Yang

et al. 2023

Preprint

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Background Modified Krackow, Bunnell, and Kessler sutures under different suture incisions can be used to directly suture ruptured Achilles tendons, but different suture techniques have various advantages and disadvantages. This study aimed to discuss the clinical effects of different suture techniques with different incision sizes. Methods This study retrospectively recruited and classified 159 patients with acute Achilles tendon injuries into minimally invasive surgery (MIS) and open surgery (OS) following operation incision size. Patients were subdivided into MIS-Krackow, MIS-Bunnell, MIS-Kessler, OS-Krackow, OS-Bunnell, and OS-Kessler. Age, sex, length of stay, creatine kinase levels (CK) pre- and postoperatively, incision length, operation time, intraoperative bleeding, AOFAS ankle-hindfoot scale, ATRS score, and range of ankle dorsalis and plantar flexion were collected and statistically compared, as well as motion, bilateral calf circumference difference, heel-rise repetition ratio, heel-rise height ratio, blood flow velocity in Achilles tendon, and complications. Results Length of stay, postoperative CK levels, surgical bleeding, and pain medication dosage demonstrated significant differences between the MIS and OS groups (P < 0.001). Operative time demonstrated significant differences between the MB:OKa, MB:OB, MKs:MKa, MKs:OKa, MKs:OB, MKs:OKs, and OKa:Oks groups (P < 0.05). Incision length demonstrated significant differences between the MB:MKa and MIS:OS groups (P < 0.05). The mean systolic blood flow velocity of the MB:MKa, MB:OKa, MB:OB, MKs:OKa, MKa:OB, MKa:OKs, OKa:OB, and OKa:OKs groups were different at 1 week postoperatively (P < 0.05). MB:MKs, MB:MKa, MB:OKa, MKs:OB, MKa:OKs, OKa:OB, and OKa:OKs groups demonstrated significant differences at 8 weeks postoperatively (P < 0.05). The dorsiflexion range of motion of MIS:OS was significantly different at 6 weeks postoperatively (P < 0.05). AOFAS demonstrated significant differences between the MIS and OS groups, except for the MKs:OKa and MKs:OB groups (P < 0.05). Only the AOFAS of the MB:OKs, MB:OB, MKa:OB, and MKa:OKs groups were significantly different at 24 postoperatively (P < 0.05). All indexes demonstrated no difference at 48 postoperatively (P > 0.05). Complications included Achilles tendon adhesion in 7 cases (1, 3, 1, and 2 cases in the OKa, OKs, OB, and MKs groups, respectively). Nerve injury occurred in two cases (MKa and MB groups, respectively). Incision infection occurred in 6 patients (3, 2, and 1 in the OKa, OB, and OKs groups, respectively). Achilles tendon re-rupture occurred in 7 cases (5 in the MKs group and 2 in the OKs group). The excellent and good rates of MKa, MB, MKs, Oka, OB, and OKs were 92.0%, 100%, 87.0%, 96.3%, 100%, and 93.1% as assessed by Arnerlind-holm, with no significant differences between the six groups. Conclusions Both OS and MIS are safe and effective in treating Achilles tendon rupture. Among them, MIS caused less secondary trauma and better ankle ROM and AOFAS scores in the previous period, but this difference was not significant at 24 and 48 weeks of follow-up. Krackow’s operation time was longer and the intensity was higher compared with the three suture methods of the two surgical methods, but the local blood flow rate of the Achilles tendon was significantly worse than Bunnell and Kessler. Additionally, Kessler was easier to operate and had better blood transport than Krackow, but the intensity was poor and the probability of complications was higher than the other two groups. Bunnell has better overall performance, less blood flow impact, and fewer complications, and is recommended as the choice of suture method for percutaneous surgery.

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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

Cited by 14 publications

References 22 publications

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture

What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Clinical effect of three suture methods on acute Achilles tendon rupture under two types of incisions

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