Abstract
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), modified triple Kessler (n = 1), triple bundle (n = 1), a multifilament 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 first four positions in the ranking, followed by the multifilament stainless steel cable-crimp and Percutaneous Achilles Repair System Midsubstance techniques. Concerning elongation after cyclic loading, the triple Kessler was ranked first, followed by the Achillon and Percutaneous Achilles Repair System Midsubstance techniques. A negligible correlation between ranks was found (rs = 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 modified triple Kessler stitch showed the highest probability of ranking first.
Level of evidence
Level IV.
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Abbreviations
- ATR:
-
Achilles tendon rupture
- MFSS:
-
Multifilament stainless steel
- N:
-
Newtons
- NMA:
-
Network meta-analysis
- PARS:
-
Percutaneous Achilles Repair System
- PRISMA:
-
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- SUCRA:
-
Surface under the cumulative ranking curve
References
Agres AN, Duda GN, Gehlen TJ, Arampatzis A, Taylor WR, Manegold S (2015) Increased unilateral tendon stiffness and its effect on gait 2–6 years after Achilles tendon rupture. Scand J Med Sci Sports 25:860–867
Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P (2002) Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 84:161–170
Aufwerber S, Edman G, Grävare Silbernagel K, Ackermann PW (2020) Changes in tendon elongation and muscle atrophy over time after Achilles tendon rupture repair: a prospective cohort study on the effects of early functional mobilization. Am J Sports Med 48:3296–3305
Barber FA, Herbert MA, Coons DA, Boothby MH (2006) Sutures and suture anchors—update 2006. Arthroscopy 22:1063-1069.e2
Barber FA, McGarry JE, Herbert MA, Anderson RB (2008) A biomechanical study of Achilles tendon repair augmentation using GraftJacket matrix. Foot Ankle Int 29:329–333
Berlet GC, Hyer CF, Lee TH, Blum BE (2014) Collagen ribbon augmentation of Achilles tendon tears: a biomechanical evaluation. J Foot Ankle Surg 53:298–302
Bishop ME, Comer CD, Kane JM, Maltenfort MG, Raikin SM (2017) Open repair of acute Achilles tendon ruptures: is the incidence of clinically significant wound complications overestimated? Foot Ankle Orthop 2:2473011417699834
Brorsson A, Willy RW, Tranberg R, Grävare Silbernagel K (2017) Heel-rise height deficit 1 year after Achilles tendon rupture relates to changes in ankle biomechanics 6 years after injury. Am J Sports Med 45:3060–3068
Cipriani A, Higgins JPT, Geddes JR, Salanti G (2013) Conceptual and technical challenges in network meta-analysis. Ann Intern Med 159:130–137
Clanton TO, Haytmanek CT, Williams BT, Civitarese DM, Turnbull TL, Massey MB, Wijdicks CA, LaPrade RF (2015) A biomechanical comparison of an open repair and 3 minimally invasive percutaneous achilles tendon repair techniques during a simulated, progressive rehabilitation protocol. Am J Sports Med 43:1957–1964
Cook KD, Clark G, Lui E, Vajaria G, Wallace GF (2010) Strength of braided polyblend polyethylene sutures versus braided polyester sutures in Achilles tendon repair: a cadaveric study. J Am Podiatr Med Assoc 100:185–188
Cottom JM, Baker JS, Richardson PE, Maker JM (2017) Evaluation of a new knotless suture anchor repair in acute Achilles tendon ruptures: a biomechanical comparison of three techniques. J Foot Ankle Surg 56:423–427
Davis WL, Singerman R, Labropoulos PA, Victoroff B (1999) Effect of ankle and knee position on tension in the Achilles tendon. Foot Ankle Int 20:126–131
Demetracopoulos CA, Gilbert SL, Young E, Baxter JR, Deland JT (2014) Limited-open Achilles tendon repair using locking sutures versus nonlocking sutures: an in vitro model. Foot Ankle Int 35:612–618
Deng S, Sun Z, Zhang C, Chen G, Li J (2017) Surgical treatment versus conservative management for acute Achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. J Foot Ankle Surg 56:1236–1243
Dias S, Welton NJ, Caldwell DM, Ades AE (2010) Checking consistency in mixed treatment comparison meta-analysis. Stat Med 29:932–944
Diniz P, Pacheco J, Guerra-Pinto F, Pereira H, Ferreira FC, Kerkhoffs G (2020) Achilles tendon elongation after acute rupture: is it a problem? A systematic review. Knee Surg Sports Traumatol Arthrosc 28(12):4011–4030
Frosch S, Buchhorn G, Hawellek T, Walde TA, Lehmann W, Hubert J (2020) Comparison of the double loop knot stitch and Kessler stitch for Achilles tendon repair: A biomechanical cadaver study. PLoS ONE 15:e0243306
Ganestam A, Kallemose T, Troelsen A, Barfod KW (2016) Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients. Knee Surg Sports Traumatol Arthrosc 24:3730–3737
Gebauer M, Beil FT, Beckmann J, Sárváry AM, Ueblacker P, Ruecker AH, Holste J, Meenen NM (2007) Mechanical evaluation of different techniques for Achilles tendon repair. Arch Orthop Trauma Surg 127:795–799
Hayden JA, van der Windt DA, Cartwright JL, Côté P, Bombardier C (2013) Assessing bias in studies of prognostic factors. Ann Intern Med 158:280–286
Heikkinen J, Lantto I, Piilonen J, Flinkkilä T, Ohtonen P, Siira P, Laine V, Niinimäki J, Pajala A, Leppilahti J (2017) Tendon length, calf muscle atrophy, and strength deficit after acute Achilles tendon rupture: long-term follow-up of patients in a previous study. J Bone Joint Surg Am 99:1509–1515
Heitman DE, Ng K, Crivello KM, Gallina J (2011) Biomechanical comparison of the Achillon tendon repair system and the Krackow locking loop technique. Foot Ankle Int 32:879–887
Herbort M, Haber A, Zantop T, Gosheger G, Rosslenbroich S, Raschke MJ, Petersen W (2008) Biomechanical comparison of the primary stability of suturing Achilles tendon rupture: a cadaver study of Bunnell and Kessler techniques under cyclic loading conditions. Arch Orthop Trauma Surg 128:1273–1277
Higgins JPT, Li T, Deeks JJ (2019) Chapter 6: choosing effect measures and computing estimates of effect. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) Cochrane handbook systematic reviews of interventions version 6.1 (updated September 2020). Cochrane. Available from www.training.cochrane.org/handbook
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) (2020) Cochrane handbook for systematic reviews of interventions version 6.1 (updated September 2020). Cochrane. Available from: www.training.cochrane.org/handbook
von Hippel PT (2015) The heterogeneity statistic I2 can be biased in small meta-analyses. BMC Med Res Methodol. https://doi.org/10.1186/s12874-015-0024-z
Huffard B, O’Loughlin PF, Wright T, Deland J, Kennedy JG (2008) Achilles tendon repair: Achillon system vs. Krackow suture: an anatomic in vitro biomechanical study. Clin Biomech 23:1158–1164
Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, Ioannidis JPA, Straus S, Thorlund K, Jansen JP, Mulrow C, Catalá-López F, Gøtzsche PC, Dickersin K, Boutron I, Altman DG, Moher D (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162:777–784
Jaakkola JI, Hutton WC, Beskin JL, Lee GP (2000) Achilles tendon rupture repair: biomechanical comparison of the triple bundle technique versus the Krakow locking loop technique. Foot Ankle Int 21:14–17
Jandacka D, Silvernail JF, Uchytil J, Zahradnik D, Farana R, Hamill J (2017) Do athletes alter their running mechanics after an Achilles tendon rupture? J Foot Ankle Res. https://doi.org/10.1186/s13047-017-0235-0
Jordan MC, Boelch S, Jansen H, Meffert RH, Hoelscher-Doht S (2016) Does plastic suture deformation induce gapping after tendon repair? A biomechanical comparison of different suture materials. J Biomech 49:2607–2612
Kadakia AR, Dekker RG, Ho BS (2017) Acute Achilles tendon ruptures: an update on treatment. J Am Acad Orthop Surg 25:23–31
Kangas J, Pajala A, Ohtonen P, Leppilahti J (2007) Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med 35:59–64
Kannus P, Józsa L (1991) Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 73:1507–1525
Krackow KA, Thomas SC, Jones LC (1988) Ligament-tendon fixation: analysis of a new stitch and comparison with standard techniques. Orthopedics 11:909–917
Krahn U, Binder H, König J (2013) A graphical tool for locating inconsistency in network meta-analyses. BMC Med Res Methodol. https://doi.org/10.1186/1471-2288-13-35
Krahn U, Binder H, König J (2014) Visualizing inconsistency in network meta-analysis by independent path decomposition. BMC Med Res Methodol. https://doi.org/10.1186/1471-2288-14-131
Lantto I, Heikkinen J, Flinkkilä T, Ohtonen P, Leppilahti J (2015) Epidemiology of Achilles tendon ruptures: increasing incidence over a 33-year period. Scand J Med Sci Sports 25:e133-138
Lee SJ, Goldsmith S, Nicholas SJ, McHugh M, Kremenic I, Ben-Avi S (2008) Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of Achilles tendon repairs. Foot Ankle Int 29:427–432
Leppilahti J, Puranen J, Orava S (1996) Incidence of Achilles tendon rupture. Acta Orthop Scand 67:277–279
Li T, Puhan MA, Vedula SS, Singh S, Dickersin K, The Ad Hoc Network Meta-analysis Methods Meeting Working Group (2011) Network meta-analysis-highly attractive but more methodological research is needed. BMC Med. https://doi.org/10.1186/1741-7015-9-79
Longo UG, Lamberti A, Maffulli N, Denaro V (2010) Tendon augmentation grafts: a systematic review. Br Med Bull 94:165–188
Lumley T (2002) Network meta-analysis for indirect treatment comparisons. Stat Med 21:2313–2324
Maffulli N, Waterston SW, Squair J, Reaper J, Douglas AS (1999) Changing incidence of Achilles tendon rupture in Scotland: a 15-year study. Clin J Sport Med 9:157–160
Magnussen RA, Glisson RR, Moorman CT (2011) Augmentation of Achilles tendon repair with extracellular matrix xenograft: a biomechanical analysis. Am J Sports Med 39:1522–1527
Manegold S, Tsitsilonis S, Gehlen T, Kopf S, Duda GN, Agres AN (2018) Alterations in structure of the muscle-tendon unit and gait pattern after percutaneous repair of Achilles tendon rupture with the Dresden instrument. Foot Ankle Surg 25(4):529–533
Maquirriain J (2011) Achilles tendon rupture: avoiding tendon lengthening during surgical repair and rehabilitation. Yale J Biol Med 84:289–300
Mccomis GP, Nawoczenski DA, Dehaven KE (1997) Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am 79:1799–1808
McCoy BW, Haddad SL (2010) The strength of achilles tendon repair: a comparison of three suture techniques in human cadaver tendons. Foot Ankle Int 31:701–705
Mezzarobba S, Bortolato S, Giacomazzi A, Fancellu G, Marcovich R, Valentini R (2012) Percutaneous repair of Achilles tendon ruptures with Tenolig: quantitative analysis of postural control and gait pattern. Foot 22:303–309
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097
Mortensen NH, Saether J, Steinke MS, Staehr H, Mikkelsen SS (1992) Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study. Orthopedics 15:899–903
Nguyen TP, Keyt LK, Herfat S, Gordon L, Palanca A (2020) Biomechanical study of a multifilament stainless steel cable crimp system versus a multistrand ultra-high molecular weight polyethylene polyester suture Krackow technique for Achilles tendon rupture repair. J Foot Ankle Surg 59:86–90
Norman GR, Sloan JA, Wyrwich KW (2003) Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care 41:582–592
Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A (2016) Rayyan—a web and mobile app for systematic reviews. Syst Rev. https://doi.org/10.1186/s13643-016-0384-4
Powell HC, Silbernagel KG, Brorsson A, Tranberg R, Willy RW (2018) Individuals post Achilles tendon rupture exhibit asymmetrical knee and ankle kinetics and loading rates during a drop countermovement jump. J Orthop Sports Phys Ther 48:34–43
R Core Team (2019) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria
Rawson S, Cartmell S, Wong J (2013) Suture techniques for tendon repair; a comparative review. Muscles Ligaments Tendons J 3:220–228
Rücker G (2012) Network meta-analysis, electrical networks and graph theory. Res Synth Methods 3:312–324
Rücker G, Krahn U, König J, Efthimiou O, Schwarzer G (2020) netmeta: network meta-analysis using frequentist methods. R package version 1.3-0. https://CRAN.R-project.org/package=netmeta
Rücker G, Schwarzer G (2015) Ranking treatments in frequentist network meta-analysis works without resampling methods. BMC Med Res Methodol. https://doi.org/10.1186/s12874-015-0060-8
Sadoghi P, Rosso C, Valderrabano V, Leithner A, Vavken P (2012) Initial Achilles tendon repair strength—synthesized biomechanical data from 196 cadaver repairs. Int Orthop 36:1947–1951
Salanti G, Ades AE, Ioannidis JPA (2011) Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol 64:163–171
Salanti G, Giovane CD, Chaimani A, Caldwell DM, Higgins JPT (2014) Evaluating the quality of evidence from a network meta-analysis. PLOS One 9:e99682
Schepull T, Kvist J, Andersson C, Aspenberg P (2007) Mechanical properties during healing of Achilles tendon ruptures to predict final outcome: a pilot Roentgen stereophotogrammetric analysis in 10 patients. BMC Musculoskelet Disord. https://doi.org/10.1186/1471-2474-8-116
Schepull T, Kvist J, Aspenberg P (2012) Early E-modulus of healing Achilles tendons correlates with late function: similar results with or without surgery. Scand J Med Sci Sports 22:18–23
Sherman SL (2018) Editorial commentary: the Krackow Stitch: more than 30 years of tendon repair and still holding strong. Arthroscopy 34:669–670
Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal SB (2017) The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27607 patients. Bone Joint J 99B:78–86
Shim SR, Kim S-J, Lee J, Rücker G (2019) Network meta-analysis: application and practice using R software. Epidemiol Health 41:e2019013
Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M (2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am 94:2136–2143
Tengman T, Riad J (2013) Three-dimensional gait analysis following achilles tendon rupture with nonsurgical treatment reveals long-term deficiencies in muscle strength and function. Orthop J Sports Med 1:2325967113504734
Troop RL, Losse GM, Lane JG, Robertson DB, Hastings PS, Howard ME (1995) Early motion after repair of Achilles tendon ruptures. Foot Ankle Int 16:705–709
Valkering KP, Aufwerber S, Ranuccio F, Lunini E, Edman G, Ackermann PW (2017) Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response: a single-blinded randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 25:1807–1816
Van Dyke RO, Chaudhary SA, Gould G, Trimba R, Laughlin RT (2017) Biomechanical head-to-head comparison of 2 sutures and the giftbox versus Bunnell techniques for midsubstance achilles tendon ruptures. Orthop J Sports Med 5:232596711770747
Willy RW, Brorsson A, Powell HC, Willson JD, Tranberg R, Grävare Silbernagel K (2017) Elevated knee joint kinetics and reduced ankle kinetics are present during jogging and hopping after achilles tendon ruptures. Am J Sports Med 45:1124–1133
Wisbeck JM, Parks BG, Schon LC (2012) Xenograft scaffold full-wrap reinforcement of Krackow achilles tendon repair. Orthopedics 35:e331-334
Wu Y, Mu Y, Yin L, Wang Z, Liu W, Wan H (2019) Complications in the management of acute achilles tendon rupture: a systematic review and network meta-analysis of 2060 patients. Am J Sports Med 47:2251–2260
Wüst DM, Meyer DC, Favre P, Gerber C (2006) Mechanical and handling properties of braided polyblend polyethylene sutures in comparison to braided polyester and monofilament polydioxanone sutures. Arthroscopy 22:1146–1153
Yammine K, Assi C (2017) Efficacy of repair techniques of the Achilles tendon: a meta-analysis of human cadaveric biomechanical studies. Foot 30:13–20
Zellers JA, Cortes DH, Pohlig RT, Silbernagel KG (2019) Tendon morphology and mechanical properties assessed by ultrasound show change early in recovery and potential prognostic ability for 6-month outcomes. Knee Surg Sports Traumatol Arthrosc 27(9):2831–2839
Zhao J-G, Meng X-H, Liu L, Zeng X-T, Kan S-L (2017) Early functional rehabilitation versus traditional immobilization for surgical Achilles tendon repair after acute rupture: a systematic review of overlapping meta-analyses. Sci Rep. https://doi.org/10.1038/srep39871
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The authors acknowledge the financial support from Fundação para a Ciência e a Tecnologia (FCT-MEC), Portugal, through the research unit iBB [UIDB/04565/2020].
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PD designed the systematic review protocol, screened and selected studies, extracted and analyzed data, performed network meta-analysis and drafted the manuscript. JP screened and selected studies and extracted data. RMF designed the systematic review protocol, provided guidance in the quantitative synthesis and revised the manuscript. HP and FCF revised the manuscript. GK designed the systematic review protocol, supervised the selection of studies and revised the manuscript. All authors read and approved the final manuscript.
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Diniz, P., Pacheco, J., Fernandes, R.M. et al. Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies. Knee Surg Sports Traumatol Arthrosc 31, 1644–1657 (2023). https://doi.org/10.1007/s00167-021-06613-9
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DOI: https://doi.org/10.1007/s00167-021-06613-9