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Knee Surgery, Sports Traumatology, Arthroscopy

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Open Access 17-05-2023 | ANKLE

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

Authors: Nicola Maffulli, Alessandro Bartoli, Giuliano Sammaria, Filippo Migliorini, Jon Karlsson, Francesco Oliva

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 10/2023

Abstract

Purpose

After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport.

Methods

The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias.

Results

Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks.

Conclusion

In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function.

Level of evidence

Level IV.

Azab E, Youssef AR (2021) Biocompatibility evaluation of human and porcine acellular dermal matrix on human primary gingival fibroblasts: in vitro comparative study. Eur J Dent. https://doi.org/10.1055/s-0041-1727551CrossRefPubMedPubMedCentral

Barrera Oro F, Sikka RS, Wolters B, Graver R, Boyd JL, Nelson B, Swiontkowski MF (2011) Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction. Arthroscopy. https://doi.org/10.1016/j.arthro.2011.04.008CrossRefPubMed

Carmont MR, Silbernagel KG, Nilsson-Helander K, Mei-Dan O, Karlsson J, Maffulli N (2013) Cross cultural adaptation of the achilles tendon total rupture score with reliability, validity and responsiveness evaluation. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-012-2146-8CrossRefPubMed

Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports. https://doi.org/10.1034/j.1600-0838.2000.010001002.xCrossRefPubMed

Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Bosma E, van Raaij TM, Munzebrock AV, Zijlstra WP, Zwerver J, Reininga IHF (2019) The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study. BMC Musculoskelet Disord. https://doi.org/10.1186/s12891-019-2437-zCrossRefPubMedPubMedCentral

Dederer KM, Tennant JN (2019) Anatomical and functional considerations in Achilles tendon lesions. Foot Ankle Clin. https://doi.org/10.1016/j.fcl.2019.04.001CrossRefPubMed

Dhammi IK, Rehan-Ul-Haq KS (2015) Graft choices for anterior cruciate ligament reconstruction. Indian J Orthop. https://doi.org/10.4103/0019-5413.152393CrossRefPubMedPubMedCentral

Doege J, Ayres JM, Mackay MJ, Tarakemeh A, Brown SM, Vopat BG, Mulcahey MK (2021) Defining return to sport: a systematic review. Orthop J Sports Med. https://doi.org/10.1177/23259671211009589CrossRefPubMedPubMedCentral

Dumbre Patil SS, Dumbre Patil VS, Basa VR, Dombale AB (2014) Semitendinosus tendon autograft for reconstruction of large defects in chronic Achilles tendon ruptures. Foot Ankle Int. https://doi.org/10.1177/1071100714531228CrossRefPubMed

10.

El Shazly O, Abou El Soud MM, El Mikkawy DM, El Ganzoury I, Ibrahim AM (2014) Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft for chronic rupture of Achilles tendon: clinical and isokinetic evaluation. Arthroscopy. https://doi.org/10.1016/j.arthro.2014.02.019CrossRefPubMed

11.

Fess EE, Gettle KS, Philips CA, Janson JR (2005) Hand and Upper Extremity Splinting (Third Edition). 397–436

12.

Fishman JA, Patience C (2004) Xenotransplantation: infectious risk revisited. Am J Transplant. https://doi.org/10.1111/j.1600-6143.2004.00542.xCrossRefPubMedPubMedCentral

13.

Gedam PN, Rushnaiwala FM (2016) Endoscopy-assisted achilles tendon reconstruction with a central turndown flap and semitendinosus augmentation. Foot Ankle Int. https://doi.org/10.1177/1071100716666365CrossRefPubMed

14.

Hao YJ, Wang AG, Fan JQ, Zhang ZY, Feng SM, Chang BQ (2020) The reconstruction of Myerson type III chronic Achilles tendon rupture by using the total arthroscopic technique combined with free semitendinosus tendon and gracilis tendon autograft. Zhonghua Wai Ke Za Zhi. https://doi.org/10.3760/cma.j.cn112139-20200306-00194CrossRefPubMed

15.

Hollawell S, Baione W (2015) Chronic Achilles tendon rupture reconstructed with achilles tendon allograft and xenograft combination. J Foot Ankle Surg. https://doi.org/10.1053/j.jfas.2014.09.006CrossRefPubMed

16.

Howick JCI, Glasziou P, Greenhalgh T, Carl Heneghan, Liberati A, Moschetti I, Phillips B, Thornton H, Goddard O, Hodgkinson M (2011) The 2011 Oxford CEBM Levels of Evidence. Oxford Centre for Evidence-Based Medicine. https://www.cebm.net/index.aspx?o=5653

17.

Höhne C (2014) Postoperative nausea and vomiting in pediatric anesthesia. Curr Opin Anaes-thesiol. https://doi.org/10.1097/ACO.0000000000000073CrossRef

18.

Jiang XJ, Shen JJ, Huang JF, Tong PJ (2019) Reconstruction of Myerson type III chronic Achilles tendon ruptures using semitendinosus tendon and gracilis tendon autograft. J Orthop Surg (Hong Kong). https://doi.org/10.1177/2309499019832717CrossRefPubMed

19.

Jiménez-Carrasco C, Ammari-Sánchez-Villanueva F, Prada-Chamorro E, García-Guirao AJ, Tejero S (2023) Allograft and autologous reconstruction techniques for neglected achilles tendon rupture: a mid-long-term follow-up analysis. J Clin Med. https://doi.org/10.3390/jcm12031135CrossRefPubMedPubMedCentral

20.

Khiami F, Di Schino M, Sariali E, Cao D, Rolland E, Catonné Y (2013) Treatment of chronic Achilles tendon rupture by shortening suture and free sural triceps aponeurosis graft. Orthop Traumatol Surg Res. https://doi.org/10.1016/j.otsr.2013.03.021CrossRefPubMed

21.

Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. https://doi.org/10.1177/107110079401500701CrossRefPubMed

22.

Kuwada GT (1990) Classification of tendon Achillis rupture with consideration of surgical re-pair techniques. J Foot Surg 29(4):361–365PubMed

23.

Lee DK (2007) Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures. J Foot Ankle Surg. https://doi.org/10.1053/j.jfas.2007.05.007CrossRefPubMed

24.

Liles J, Adams SB (2019) Management of complications of Achilles tendon surgery. Foot Ankle Clin. https://doi.org/10.1016/j.fcl.2019.04.008CrossRefPubMed

25.

Maffulli N (1996) Clinical tests in sports medicine: more on Achilles tendon. Br J Sports Med. https://doi.org/10.1136/bjsm.30.3.250CrossRefPubMedPubMedCentral

26.

Maffulli N, Ajis A (2008) Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am. https://doi.org/10.2106/JBJS.G.01241CrossRefPubMed

27.

Maffulli N, Del Buono A, Spiezia F, Maffulli GD, Longo UG, Denaro V (2013) Less-invasive semitendinosus tendon graft augmentation for the reconstruction of chronic tears of the Achilles tendon. Am J Sports Med. https://doi.org/10.1177/0363546512473819CrossRefPubMed

28.

Maffulli N, Leadbetter WB (2005) Free gracilis tendon graft in neglected tears of the achilles tendon. Clin J Sport Med. https://doi.org/10.1097/01.jsm.0000152714.05097.efCrossRefPubMed

29.

Maffulli N, Longo UG, Gougoulias N, Denaro V (2008) Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon. BMC Musculoskelet Disord. https://doi.org/10.1186/1471-2474-9-100CrossRefPubMedPubMedCentral

30.

Maffulli N, Loppini M, Longo UG, Maffulli GD, Denaro V (2013) Minimally invasive reconstruction of chronic Achilles tendon ruptures using the ipsilateral free semitendinosus tendon graft and interference screw fixation. Am J Sports Med. https://doi.org/10.1177/0363546513479017CrossRefPubMed

31.

Maffulli N, Spiezia F, Pintore E, Longo UG, Testa V, Capasso G, Denaro V (2012) Peroneus brevis tendon transfer for reconstruction of chronic tears of the Achilles tendon: a long-term follow-up study. J Bone Joint Surg Am. https://doi.org/10.2106/JBJS.K.00200CrossRefPubMed

32.

Maffulli N, Spiezia F, Testa V, Capasso G, Longo UG, Denaro V (2012) Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon. J Bone Joint Surg Am. https://doi.org/10.2106/JBJS.K.00869CrossRefPubMed

33.

Maffulli N, Via AG, Oliva F (2017) Chronic Achilles tendon rupture. Open Orthop J. https://doi.org/10.2174/1874325001711010660CrossRefPubMedPubMedCentral

34.

Maffulli N, Ziello S, Maisto G, Migliorini F, Oliva F (2023) Local tendon transfers for chronic ruptures of the Achilles tendon: a systematic review. J Clin Med. https://doi.org/10.3390/jcm12020707CrossRefPubMedPubMedCentral

35.

Magnussen RA, Glisson RR, Moorman CT (2011) Augmentation of Achilles tendon repair with extracellular matrix xenograft: a biomechanical analysis. Am J Sports Med. https://doi.org/10.1177/0363546510397815CrossRefPubMed

36.

Myerson MS (1999) Achilles tendon ruptures. Instr Course Lect 48:219–230PubMed

37.

Nilsson N, Gunnarsson B, Carmont MR, Brorsson A, Karlsson J, Nilsson-Helander K (2022) Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-06943-2CrossRefPubMedPubMedCentral

38.

Nilsson-Helander K, Thomeé R, Silbernagel KG, Grävare-Silbernagel K, Thomeé P, Faxén E, Eriksson BI, Karlsson J (2007) The Achilles tendon total rupture score (ATRS): development and validation. Am J Sports Med. https://doi.org/10.1177/0363546506294856CrossRefPubMed

39.

Oda H, Sano K, Kunimasa Y, Komi PV, Ishikawa M (2017) Neuromechanical modulation of the achilles tendon during bilateral hopping in patients with unilateral Achilles tendon rupture, over 1 year after surgical repair. Sports Med. https://doi.org/10.1007/s40279-016-0629-3CrossRefPubMed

40.

Ofili KP, Pollard JD, Schuberth JM (2016) The neglected Achilles tendon rupture repaired with allograft: a review of 14 cases. J Foot Ankle Surg. https://doi.org/10.1053/j.jfas.2016.01.001CrossRefPubMed

41.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hrobjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. https://doi.org/10.1136/bmj.n71CrossRefPubMedPubMedCentral

42.

Papalia R, Franceschi F, D’Adamio S, Diaz Balzani L, Maffulli N, Denaro V (2015) Hamstring tendon regeneration after harvest for anterior cruciate ligament reconstruction: a systematic review. Arthroscopy. https://doi.org/10.1016/j.arthro.2014.11.015CrossRefPubMed

43.

Plaass C (2013) Chronic Achilles tendon lesion minimally invasive treatment with autologous semitendinosus graft. Z Orthop Unfall. https://doi.org/10.1055/s-0033-1349250CrossRefPubMed

44.

Qi J, Xia Y, Wang Y, Zhao L, Yao C (2013) Effectiveness of hamstring tendon and flexor hallucis longus tendon autograft for Achilles tendon defects reconstruction. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 27(10):1202–1205PubMed

45.

Sarzaeem MM, Lemraski MM, Safdari F (2012) Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-011-1703-xCrossRefPubMed

46.

Shoaib A, Mishra V (2017) Surgical repair of symptomatic chronic Achilles tendon rupture using synthetic graft augmentation. Foot Ankle Surg. https://doi.org/10.1016/j.fas.2016.04.006CrossRefPubMed

47.

Song YJ, Chen G, Jia SH, Xu WB, Hua YH (2020) Good outcomes at mid-term following the reconstruction of chronic Achilles tendon rupture with semitendinosus allograft. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5113-1CrossRefPubMedPubMedCentral

48.

Tsukada K, Yasui Y, Kubo M, Miki S, Matsui K, Sasahara J, Kawano H, Miyamoto W (2021) Operative outcome of side-locking loop suture technique accompanied by autologous semitendinosus tendon grafting for chronic rupture of Achilles tendon. Foot Ankle Orthop. https://doi.org/10.1177/24730114211003541CrossRefPubMedPubMedCentral

49.

Usuelli FG, D’Ambrosi R, Manzi L, Indino C, Villafañe JH, Berjano P (2017) Clinical outcomes and return to sports in patients with chronic Achilles tendon rupture after minimally invasive reconstruction with semitendinosus tendon graft transfer. Joints. https://doi.org/10.1055/s-0037-1608661CrossRefPubMedPubMedCentral

50.

Vinagre G, Kennedy NI, Chahla J, Cinque ME, Hussain ZB, Olesen ML, LaPra-de RF (2017) Hamstring graft preparation techniques for anterior cruciate ligament reconstruction. Arthrosc Tech. https://doi.org/10.1016/j.eats.2017.08.031CrossRefPubMedPubMedCentral

51.

Vuldzhev M, Linkwinstar J, Koynarski F (2022) Case series report: reconstruction of chronic Achilles tendon rupture with semitendinosus autograft combined with vulpius technique. Cureus. https://doi.org/10.7759/cureus.32325CrossRefPubMedPubMedCentral

52.

Wilson TW, Zafuta MP, Zobitz M (1999) A biomechanical analysis of matched bone-patellar tendon-bone and double-looped semitendinosus and Gracilis tendon grafts. Am J Sports Med. https://doi.org/10.1177/03635465990270021501CrossRefPubMed

53.

Zambelli R, Pinto RZ, Magalhães JM, Lopes FA, Castilho RS, Baumfeld D, Dos Santos TR, Maffulli N (2016) Development of the Brazilian Portuguese version of the Achilles tendon total rupture score (ATRS BrP): a cross-cultural adaptation with reliability and construct validity evaluation. BMC Sports Sci Med Rehabil. https://doi.org/10.1186/s13102-016-0034-0CrossRefPubMedPubMedCentral

Title: Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review
Authors: Nicola Maffulli
Alessandro Bartoli
Giuliano Sammaria
Filippo Migliorini
Jon Karlsson
Francesco Oliva
Publication date: 17-05-2023
Publisher: Springer Berlin Heidelberg
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 10/2023
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-023-07446-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

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