From 2016 all patients with ATR were prospectively evaluated at Princess Royal Hospital Telford. The Research and Innovation Committee of Shrewsbury & Telford Hospital NHS Trust have approved the study and confirmed that this study is Service Evaluation. All patients gave their informed consent for inclusion in the study and publication of their anonymous data. All patients demonstrated the triad of a palpable gap, the absence of plantar flexion with the calf squeeze test and an increased relative ATRA [19] confirming the diagnosis of Achilles tendon rupture [21]. Patients were counselled of the outcomes, the rates and burden of complications of both operative and non-operative management. Patients therefore made an informed choice of treatment. Patients received minimally invasive surgery, and were included if they received surgery within 14 days from the injury. Patients were followed up until 12 months following injury. The outcome of these patients has been subsequently reported [18–20] and patients who sustained re-rupture have been evaluated for the patient characteristics and the mode of failure of the repair at re-repair or reconstruction (Table 1). Repairs that failed did so consistently due to suture pull out from the distal stump in all patients, and patients were heavy or had high pre-injury Tegner [22] level of activity. Therefore, a TO rather than TT suture placement was therefore used in the presence of one of the following criteria: palpable tendon gap was within 2cm of the tendon insertion, patient weight ≥ 105kg, had a high pre-injury Tegner scale ≥ 8 (Fig. 1). The standard technique was used if the palpable tendon gap was more proximal than 2cm from the tendon insertion [6]. Patients with musculotendinous ruptures and those presenting at more than 2 weeks following injury were excluded.
Table 1
Demographic characteristics and mechanism of re-rupture following MIR prior to 2016.
Age | Gender | Time following repair/weeks | Weight/Kg | Tegner | Mechanism of repair failure | Mode of failure |
---|
51 | M | 9 | 145 | 5 | Spontaneous | Distal pull out |
47 | F | 8 | 105 | 4 | Slip shower | Distal pull out |
43 | F | 5 | 73 | 8 | Spontaneous | Distal pull out |
45 | M | 4 | 106 | 8 | Slip bath | Distal pull out |
49 | F | 12 | 115 | 6 | Spontaneous | Distal pull out |
Transosseous technique
Patients underwent a repair of the Achilles tendon rupture using a minimally invasive technique modified [19] from a previous percutaneous technique [6]. A 2cm medial longitudinal incision just proximal to the rupture site, allowed visualization of the tendon ends apposition following repair. A second 2cm longitudinal mid lateral incision at 8-10cm from the insertion was made to visualize and protect the sural nerve. Repairs were performed using a No. 2 non-absorbable polytetrafluoroethylene coated polyester suture (Fiberwire®, Arthrex, Naples, Fl) using a Bunnell configuration proximally. The distal incisions were positioned either side of the Achilles insertion. A 2.5mm drill was then used to make a TO tunnel across the calcaneum at the level of the Achilles insertion. A straight 5cm needle was then passed through this hole so that 3 strands of No. 2 non-absorbable polytetrafluoroethylene coated polyester suture (Fiberwire®, Arthrex, Naples, Fl) were passed through the suture loop, and the needle withdrawn so that the sutures pass across the calcaneum. In turn either ends of the sutures were passed subcutaneously into the distal stump and tendon before emerging through the medial incision (Fig. 2a). These intra-tendinous sutures were tied with the ankle and foot held in maximal plantar flexion or reduced ATRA to the non-affected side. Knots were buried within the tendon substance, or placed anteriorly to the tendon and the fascia cruris was closed using absorbable detensioning absorbable sutures.
Transtendinous technique:
Patients underwent a repair of the Achilles tendon rupture using a minimally invasive technique [19] modified from a previous percutaneous technique [6]. The proximal suture being a modified Bunnell technique and distally a transtendinous Kessler suture. With the ankle held passively in full plantar flexion the proximal and were tied in the manner described above (Fig. 2b).
Patients receiving the TO technique received general anaesthesia and patients with the TT technique offered the choice between general or local anaesthesia. All patients received 30mls of 0.5% Bupivucaine with 1:200,000 adrenaline local anaesthetic field infiltration. Other aspects of the procedure were the same for both groups. Pre-operative flucloxacillin 1g and six weeks of low molecular weight heparin (Tinzaparin 4500iu once daily (Leo Pharma, Berkshire, UK)) were administered. Once the local anaesthetic was worn off and protective pain sensation restored, patients were encouraged to weight-bear on their metatarsal heads as tolerated by pain. The patient used a protective synthetic equinus split cast for 2 weeks and crutches. After this period, the split cast was removed only for early active movement exercises consisting of plantar flexion, inversion and eversion contractions of 10s duration performed for 10 repetitions, 3 times per day. Dorsiflexion was not permitted until 6 weeks. Weight-bearing continued using the anterior protective shell alone, secured in place using elasticated velcro straps. After the six-week time point the functional brace was discontinued and patients were given a 1.5cm in-shoe heel wedge. Departmental physiotherapy was commenced at the 6-week time point consisting of gait retraining and strengthening with double heel rises progressing to single heel rises. Stretching and plyometric exercises were avoided until the 3-month time point. No formal restrictions were given with regards to return to play, however, most patients held off returning to play until they felt comfortable to do so typically 6–9 months following rupture.
Re-repair technique:
Re-repair was performed using an incision over the rupture site scar. This was extended proximally and distally until the mode of failure could be determined, the existing suture removed and the tendon ends mobilised. If end-to-end apposition could be achieved the repair was repeated using the original technique of a modified Bunnell suture proximally and either a TO or TT Kessler suture for distal placement using 6 strands of No. 2 Fiberwire. Re-repair was performed using the original repair technique provided tendon end apposition could be achieved. Thus, TO re-rupture repair was performed using a TO technique and a TT re-rupture repair using a TT technique. A proximal V-Y plasty was performed to lengthen the proximal stump and permit end-to-end apposition in the one case where this was not possible at the re-rupture site. The larger incision enabled the repair to be augmented by a No. 2 polyglactin running circumferential suture. This technique is the same as that performed for Acute-on-Chronic repairs [23]. The post-operative regime was the same as per the original repair.
Follow-up evaluation:
Patients were reviewed at 6 weeks, 3, 6, 9 and 12 months after surgery by the same examiner (MC) with the advantage of avoiding interobserver error. Patient outcomes were included based on intention to treat, meaning that those patients who sustained re-rupture and re-repair were included in the final follow up data. Patient reported outcome and function were evaluated using the Achilles tendon Total Rupture Score (ATRS) [24], Tegner activity scale [22] and Physical Activity Scale (PAS) [25]. The pre-injury level of physical activity/patient perception of performance (PPP) was determined at the 3-month time point [20]. At each follow-up the patients were asked, “Do you think you have reached the same level of physical activity and performance as before your injury?” They were asked to categorize their response as either: not yet attained, the same or greater/improved.
Patients were examined for palpable tendon gaps and tendon continuity using a calf squeeze test. The Achilles Tendon Resting Angle (ATRA) [26] was measured following rupture, surgery, at 6 weeks and at all subsequent evaluations. The ATRA assessment has been independently validated and shown to be reliable, reproducible and responsive [26, 27]. A maximal single leg heel-rise height (HRH) [28] and calf circumference was compared with the non-affected side at 3, 6, 9, and 12 months respectively. The calf circumference was measured using a tape measure at 15cm below the medial knee joint line [26]. Heel-Rise Repetition (HRR) was assessed by counting the number of single-leg heel rises performed by the patient to exhaustion at the 12 months point. Finger-tip contact with the wall was permitted for balance. Limb Symmetry Index (LSI) for the Heel-Rise Height Index (HRHI) and Heel-Rise Repetition Index (HRRI) were determined as the maximal height of a single heel rise on the injured side/the maximal height of a single heel rise on the uninjured side x 100. The HRRI was calculated as the number of repetitions performed on the repaired side/number of repetitions on the uninjured side x 100.
All patients provided written consent for data collection and this research was considered to be service evaluation according to the Health Research Authority and consequently ethical approval was not required.
Statistical evaluation:
All data were analysed using Statistical Package for Social Sciences version 28 (IBM Corp, Armonk, NY). Patients with TO ATR were compared with the cohort of patients with TT AT repair.
Descriptive statistics were reported using mean and standard deviation (SD) and median (25th -75th percentile Inter-Quartile Range (IQR)) values. Outcomes were compared according to intention to treat i.e. patients who underwent re-repair surgery were included in final outcome. An ATRS of 80 points was considered to be good [29]. Due to the numbers of patients involved non-parametric statistics were performed Mann-Whitney U test. Categorical analysis was performed using Cross Tabs and Fischer’s Exact test. Repeated measures of the ATRA over time were compared using Two Way ANOVA. Statistical significance was taken to be < 0.05. All patients who met the inclusion criteria were included in the study. Therefore, no sample size calculation was performed as all patients were included.