Comparison of the double loop knot stitch and Kessler stitch for Achilles tendon repair: A biomechanical cadaver study

Frosch, Stephan; Buchhorn, Gottfried; Hawellek, Thelonius; Walde, Tim Alexander; Lehmann, Wolfgang; Hubert, Jan

doi:10.1371/journal.pone.0243306

Cited by 5 publications

(9 citation statements)

References 47 publications

(66 reference statements)

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“…The search strategy yielded 2949 entries. Sixteen studies met the inclusion criteria for quantitative synthesis [5, 6, 10, 12, 14, 18, 20, 23, 24, 28, 30, 46, 50, 54, 75, 77]. The study search and selection flowchart, with reasons for exclusion, is shown in Fig.…”

Section: Resultsmentioning

confidence: 99%

“…All studies described the method used to simulate an ATR, with transection using a conventional scalpel being used across all studies. This transverse cut was performed at a distance from the calcaneal insertion of 2 [24], 3 [54], 4 [5, 12, 14, 23, 30, 46, 75, 77], 4.5 [18, 28], 5 [6, 20, 50] and 6 cm [10].…”

Section: Resultsmentioning

confidence: 99%

“…Ten out of the sixteen studies reported conflicts of interest or relevant financial disclosures [5, 6, 10, 14, 20, 23, 46, 54, 75, 77], four studies reported no conflicts of interest or financial disclosures [12, 18, 28, 50], and in the remaining two studies this information was not provided [24, 30].…”

Section: Resultsmentioning

confidence: 99%

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Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies

Diniz

Pacheco

Fernandes

et al. 2021

Knee Surg Sports Traumatol Arthrosc

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Purpose Current treatment recommendations emphasize early loading, with preservation of tendon length and physiologic tension. The objective of this systematic review and network meta-analysis was to compare failure load and elongation after cyclic loading of Achilles tendon repair techniques at time-zero. Methods The databases PubMed, CENTRAL and Web of Science were searched for all published in-vitro studies comparing Achilles tendon repair techniques, or augmentation with autografts/biomaterials, and reports of failure load or elongation after cyclic loading. Only studies using human cadaveric Achilles tendons and matched pairs, or randomized specimen allocation, were selected for quantitative synthesis. A network meta-analysis per primary outcome was performed. Results were summarized as P score rankings and their validity was assessed using statistical methods. Results Sixteen studies, comprising 367 tendon repairs, were included. The following repair techniques were used (n = number of studies): Krackow (n = 8), Achillon (n = 4), double Krackow (n = 3), Bunnell (n = 3), Percutaneous Achilles Repair System (n = 3), Percutaneous Achilles Repair System Midsubstance (n = 2), Kessler (n = 3), double Kessler (n = 1), modiied triple Kessler (n = 1), triple bundle (n = 1), a multiilament stainless steel cable-crimp technique (n = 1) and a double loop knot stitch (n = 1). Five studies assessed augmentation with autografts/biomaterials. Regarding the failure load, biomaterial augmented Krackow repairs occupied the irst four positions in the ranking, followed by the multiilament stainless steel cable-crimp and Percutaneous Achilles Repair System Midsubstance techniques. Concerning elongation after cyclic loading, the triple Kessler was ranked irst, followed by the Achillon and Percutaneous Achilles Repair System Midsubstance techniques. A negligible correlation between ranks was found (r s = 0.11; p = 0.75n.s.), meaning that a higher repair tensile strength is not necessarily related to improved performance in regard to avoidance of elongation. Conclusion In the failure load network meta-analysis, biomaterial augmented Krackow repairs ranked highest, but noticeable statistical heterogeneity was found. Regarding elongation with cyclic loading, the modiied triple Kessler stitch showed the highest probability of ranking irst. Level of evidence Level IV.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies

Diniz

Pacheco

Fernandes

et al. 2021

Knee Surg Sports Traumatol Arthrosc

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“…The proximal end of Achilles tendon is sutured with three transverse crosses of sutures by using an eccentric sleeve. We simplified the complex steps of Achillon and PARS repair and decreased the number of knots, facilitating the gliding of the Achilles tendon with the surrounding tissue after long-term repair and reducing the formation of keloids [ 42 , 43 ]. So, this Mini-open repair system can reduce the risk of suture reactivity and make the broken end smoother.…”

Section: Discussionmentioning

confidence: 99%

Comparison of mini-open repair system and percutaneous repair for acute Achilles tendon rupture

Jiang

Chen

et al. 2021

BMC Musculoskelet Disord

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Background To reduce incision complications, minimally invasive operative approaches for treatment with acute Achilles tendon rupture have been developed, such as Mini-open repair and percutaneous repair. Which technique is the better surgical option? In the present study, we compared the two surgical procedures— modified Mini-open repair versus percutaneous repair—in the treatment of acute Achilles tendon rupture. Methods From January 2016 to November 2018, 68 matched patients with acute Achilles tendon rupture were divided into treatment group (Mini-open with modified Ma-Griffith technique) and control group (the Ma–Griffith technique). The patients were then treated with different surgical techniques and followed up for no less than 24 months, and the functional outcome scores and complications were retrospectively evaluated. Results The mean follow-up time in Mini-open repair group was 29.0±2.9 months, and that in control group was 27.9±2.9 months (P=0.147). The Mini-open repair group showed reliably higher American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Achilles tendon Total Rupture Score (ATRS) than the control group in functional assessment (95.0±3.8 vs. 92.3±5.3, P=0.000; 93.8±3.8 vs. 90.9±4.5,P=0.000). There was no cases of sural nerve injury in Mini-open repair group, whereas the percutaneous repair group had 5 cases of the same (P=0.027). No significant differences were found in the calf circumference (32.3±3.9 vs. 31.8±3.6) (P=0.564), range of motion of the ankle (51.3±4.8 vs. 50.5±4.2, P=0.362), or wound complications (34/0 vs. 34/0) (P=1.000) between the two groups at the end of the follow-up time. However, the percutaneous repair group had a shorter average operating time (23.1±5.2 min) than that of the Mini-open repair group (27.7±4.3 min) (P=0.000). Conclusions Acute Achilles tendon ruptures may be treated successfully with a new Mini-open repair system or percutaneous repair technique. However, the Mini-open repair system may represent a superior surgical option, since it offers advantages in terms of direct visual control of the repair, AOFAS Ankle-Hindfoot Score, Achilles tendon Total Rupture Score and risk of sural nerve palsy. Study design Case-control studies, Level of evidence, 3.

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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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Comparison of the double loop knot stitch and Kessler stitch for Achilles tendon repair: A biomechanical cadaver study

Cited by 5 publications

References 47 publications

Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies

Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies

Comparison of mini-open repair system and percutaneous repair for acute 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

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