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Treatment of Acute Achilles Tendon Rupture: Fibrin Glue versus Fibrin Glue Augmented with the Plantaris Longus Tendon
Treatment of Acute Achilles Tendon Rupture: Fibrin Glue versus Fibrin Glue Augmented with the Plantaris Longus Tendon Bernd Hohendorff, MD,1 Wolf Siepen, MD,2 and Lukas Staub, MD3 In the surgical repair of Achilles tendon ruptures, suturing is standard, although fibrin glue also has been used for repair since the 1980s. Augmentation with the plantaris longus tendon is also a popular technique; however, no study has yet compared the outcome of augmented versus only glued repair of ruptured Achilles tendons. This study compares the long-term results of surgical repair of Achilles tendon rupture with fibrin glue versus fibrin glue augmented with the plantaris longus tendon. Forty patients who had undergone Achilles tendon repair with fibrin glue took part in a follow-up examination after an average of 11.5 years. The fibrin group consisted of 16 patients and the fibrin glue augmented with plantaris longus tendon group consisted of 15 patients. The modified Thermann score (adapted from Weber) and results of an isokinetic force measurement were the same in both groups, whereas complications in the 2 groups also did not differ. We conclude that augmentation with the plantaris longus tendon is not necessary when operatively treating acute ruptured Achilles tendons with fibrin glue. Level of Clinical Evidence: 2 (The Journal of Foot & Ankle Surgery 48(4):439–446, 2009) Key Words: augmentation, outcome, rerupture, suture, Thermann score, Thompson-Dougherty test
The Achilles tendon is the strongest and thickest tendon in the human body, and it takes its name from Achilles, the warrior of Homer’s Iliad. Ambrose Pare´ first described its rupture in 1575 (1), and the earliest publication on the condition dates from 1633. Frequently, acute ruptures of the Achilles tendon occur in men and in middle-aged individuals who are in their third or fourth decade of life, most commonly those participating in physically demanding work, sports, or leisure activities. About 30% of all sports-related tendon lesions are Achilles tendon ruptures (2, 3), and the left Achilles tendon is more frequently involved than the right (4, 5). Preexisting complaints in the region of the Achilles tendon are reported in about 10% of cases of Achilles tendon rupture. Use of steroids and fluoroquinolone antibiotics are thought by some to be etiological factors (4). The treatment of
Address correspondence to Bernd Hohendorff, MD, SRO AG Langenthal, St. Urbanstrasse 67, 4900 Langenthal, Switzerland. E-mail: bernd. [email protected]. 1 Senior Physician, Department of Orthopaedics and Traumatology, SRO AG Langenthal, Langenthal, Switzerland. 2 Assistant Physician, Department of Orthopaedics and Traumatology, SRO AG Langenthal, Langenthal, Switzerland. 3 Assistant Physician and Professional Statistician, MEM Research Center University of Berne, Berne, Switzerland. Financial Disclosure: None reported. Conflict of Interest: None reported. Copyright Ó 2009 by the American College of Foot and Ankle Surgeons 1067-2516/09/4804-0005$36.00/0 doi:10.1053/j.jfas.2009.04.005
Achilles tendon ruptures remains a controversial issue. Quenu and Stoinovitch (6) first proposed surgical reconstruction in 1929. Since the early 1980s, different suture techniques have been used to reapproximate the tendon, and the use of fibrin glue also has been available since that time. The idea of using clotting substances to support hemostasis in the treatment of wounds dates from 1909, when Bergel (7) described the clotting effect of fibrin powder. In 1940 Young and Medawar (8) reunited peripheral nerves with fibrin glue in an experimental setting. But inadequate fibrinogen and lack of antifibrinolytics reduced the stability of the clots, despite the unawareness, at that time, of factor XIII and its effects. In 1972, Matras et al (9) successfully used a special cryoprecipitate of highly concentrated fibrinogen with an enhanced factor XIII content for reuniting peripheral nerves in animal experiments. The introduction of aprotinin (bovine pancreatic trypsin inhibitor) to reduce hemorrhage during surgery ended the problems with fibrinolysis and fibrin degeneration when fibrin adhesives were used to reapproximate tissues (10). The putative advantage for the use of fibrin glue as a tissue adhesive for Achilles tendon repair is that it provides a less traumatic surgical technique that enables anatomical reconstruction of the tendon fibers while avoiding suture-caused ischemia or inexact adaptation of the ruptured tendon ends (11, 12). Different studies have described augmentation techniques with artificial material or autologous tissue for strengthening the reconstructed Achilles tendon (13–23). First use of the VOLUME 48, NUMBER 4, JULY/AUGUST 2009
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plantaris longus tendon as autologous suturing material has been attributed to Streli (24, 25), although this method was mentioned in earlier publications (26, 27). To date, we are not aware of studies that describe the results of Achilles tendon ruptures treated operatively with the fibrin glue Tissucol (Baxter International Inc., Deerfield, IL) augmented with plantaris longus tendon. At our hospital, operative treatment of acute Achilles tendon ruptures is favored. The purpose of this study was to compare long-term (>10 years) results of acute Achilles tendon ruptures treated operatively with fibrin adhesive versus gluing augmented with plantaris longus tendon. We hypothesized that repair of Achilles tendon ruptures with only fibrin glue would achieve results that were comparable to the results obtained by means of fibrin glue repair augmented with plantaris longus tendon. In addition, we wanted to determine how the operated side compared with the healthy (nonoperated) side in patients who had undergone repair of their ruptured Achilles tendon, long after the repair had taken place. Patients and Methods Study Cohort Patients were selected for participation in this study based on the following 3 inclusion criteria: (1) the patient was unable to plantarflex the ankle on the injured side at the time of the initial presentation, (2) the presence of a positive ThompsonDougherty test on initial examination, and (3) surgical repair of the ruptured Achilles tendon took place within 7 days of the initial traumatic event. Patients were excluded if the initial evaluation and treatment of the rupture was delayed beyond 7 days, or the etiology of the rupture was determined to be secondary to a chronic or degenerative process rather than acute traumatic overload of the Achilles tendon. Surgical Interventions and Aftercare A medial skin incision and careful dissection of the paratenon was used to inspect and repair the ruptured Achilles tendon. The ruptured tendon ends were brushed with a small skin retractor, after which the ankle was positioned in 20 to 30 of plantarflexion and the tendon fibers were anatomically reduced. Fibrin glue (Tissucol Duo S 1.0 mL, Baxter International Inc.) was then injected in layers to secure the reduced portions of the tendon in apposition. No suture was used in the fibrin group for Achilles tendon repair. A plantaris longus tendon was always used when it was available and was not ruptured as well. The repair with fibrin glue was augmented with plantaris tendon plaited in a figure of 8 and sutured with itself in the technique suggested by Streli (24, 25). The paratenon was sutured after completing the Achilles tendon repair. Before 1999, postoperative treatment lasted 8 weeks. A circular thigh cast with 30 knee flexion and ankle plantar440
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flexion that avoided disruption of the repaired Achilles tendon was applied for 3 weeks after acute operative swelling subsided, after which a non–weight-bearing short-leg cast was applied with the ankle in 15 of equinus for the next 2 weeks. Finally, a short-leg, neutral-position walking cast was applied for 3 additional weeks. In 1999, the postoperative treatment was changed to include use of the Vacuped (Oped, Cham, Switzerland) vacuum brace system with 30 equinus position for 3 weeks, then 15 for 2 weeks, followed by 3 weeks in neutral position. Full weight bearing was allowed after 5 weeks for all cases, when the equinus position was neutral. Follow-up Examination We invited all the patients we could locate to return for long-term follow-up examination. Respondents gave informed consent and the local review board approved this follow-up study. Patient histories concerning the rupture and preexisting complaints related to the Achilles tendon were obtained. Specific items included the type of trauma related to the rupture, and whether the injury occurred at work, while participating in sports, or during free-time activities. Patients were asked to rate their current pain level from 0 (no pain) to 10 (unbearable). Complications, if any, were also recorded, including data related to delayed wound healing, infection, thrombosis, rerupture, or revision operation. The follow-up clinical evaluation included the subjective report of pain at the rim of the shoe and/or paresthesia upon contact with the surgical site, objective assessment of scar tissue, the presence or absence of adhesion, and ankle range of motion. Further data were obtained using the Thermann Score as modified by Weber et al (28) (Table 1). Isokinetic testing, in which a body segment accelerates to achieve a preselected fixed speed against an accommodating resistance, also was performed on both lower extremities using a HUMAC NORM Model 770 dynamometer (Computer Sports Medicine, Inc., Stoughton, MA). Statistical Analyses For the statistical evaluation in this relatively small sample, only nonparametric methods were used for the comparisons between the groups. The fibrin and suture groups were compared with the 2-sided Mann Whitney U test for unpaired data. For the comparison between the operated and healthy sides, the 2-sided Wilcoxon signed ranks test was used to compare these paired data. Differences in proportions were analyzed using Fisher’s exact test. Bonferroni correction was used to adjust for multiple comparisons in regard to Thermann scores, complication rates, and isokinetic tests. A total of 93 tests were performed, and the significance level was set to a = 0.05. All of the statistical analyses were
conducted on a personal computer using SAS 9.1 (SAS Institute Inc, Cary, NC).
TABLE 1 Thermann score* modified by Weber et al. (28), ascertained at the time of long-term follow-up Outcome Reduction of ankle dorsiflexion None 5 10 >10 Reduction in spontaneous plantar flexion (prone) None 5 10 >10 Reduction in calf circumference None 1 cm 2 cm >2 cm Static single-legged heel raise 1 minute 10 seconds Barely possible Impossible Thompson-Dougherty test Negative Positive Peak torque as percentage of healthy side >95% 85% 75% 65% <65% Pain None Only with maximum exertion With moderate exertion With minimal exertion At rest None Subjective loss of power Minor loss on maximum exertion Minor loss on normal exertion Moderate loss on normal exertion Severe loss Ability to perform sports At pre-injury level Minimal restriction Moderate restriction Impossible Sensitivity to meteorological (barometric pressure) changes None Present Subjective overall assessment by patient Very good Good Moderate Fair Poor Total
Points
10 5 2 0 10 5 2 0 10 5 3 0 10 5 1 0 5 0 10 8 6 2 0 10 8 3 2 0 10 8 6 2 0 10 8 3 0 5 0 10 8 6 2 0 100
*Maximum score = 100 points; very good $90, good $80 <90, moderate $70 <80, fair $60 <70, poor <60 points.
Results Demographic Characteristics of the Cohort A total of 44 Achilles tendon ruptures were treated operatively with fibrin glue between October 1987 and December 1999. Of these, 40 patients (33 men, 7 women) met our criteria for inclusion in this investigation. The remaining 4 were excluded because of delayed presentation after trauma, or degenerative or chronic Achilles tendon rupture. The median age of the patients at the time of operation was 38 years (range 25–67) in the fibrin group and 39 (range 16–80) in the augmented group (P = .58). In the fibrin group (n = 18), 8 patients were operated within 1 day of their rupture, and 10 underwent surgical repair before the seventh day following the injury. In the augmented group (n = 22), 11 patients were operated within the first day following their rupture, and 11 underwent surgical repair before the seventh day. Delayed operation beyond the first posttraumatic day was caused either by late presentation to the emergency department, or the need to attend to other medical and scheduling issues before operative intervention. At operation we found a plantaris longus tendon in 56.8% of our cases. The same 2 experienced surgeons performed all of the procedures.
Characteristics of the Cohort at Long-term Follow-up In summer 2006, the 40 patients were invited to a follow-up examination. Three of the 40 patients had died, and 1 could not be found. Another 5 patients were unable to attend the followup examination because of lack of time, although all 5 claimed to be very satisfied with the results of their operation. We therefore carried out a long-term follow-up examination on 31 (77.5%) patients who had had their ruptured Achilles tendon repaired, 16 with fibrin glue and 15 with fibrin glue augmented with plantaris longus tendon. A flow diagram of the selection process for the study sample is shown in Figure 1. Table 2 compares gender, age at operation, height, weight, body mass index, and take-off leg results for the 2 groups at longterm follow-up. In the fibrin group, trauma was sustained during activities related to work (n = 1), leisure (n = 5), or sports (n = 10). In the augmented group, trauma was related to leisure (n = 4) or sports activities (n = 11). In the fibrin group, 9 ruptures occurred on the right side, and 7 on the left; 2 patients had previous complaints of Achilles tendon pain before they ruptured the tendon. In the augmented group, 4 ruptures were on the right side, 11 on the left; 1 patient in the augmented group had complaints of Achilles tendon pain before the rupture. VOLUME 48, NUMBER 4, JULY/AUGUST 2009
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TABLE 3 Median Thermann score, modified by Weber et al. (28), ascertained at the time of the long-term follow-up visit (N = 31)
Achilles tendon ruptures treated (Oct 1987 – Dec 1999): n = 44
Outcome Excluded: n = 4
Patients included at baseline: n = 40
Fibrin group:
Augmented group:
n = 18
n = 22
Lost to Follow-up: n=2 not found: n = 1 no time: n = 1
Lost to Follow-up: n=7 died: n = 3 no time: n = 4
Follow-up:
Follow-up:
n = 16
n = 15
FIGURE 1 Selection process of the study sample.
TABLE 2 Demographic data by intervention group, ascertained at the time of the long-term follow-up visit (N = 31) Variable
Intervention Fibrin Glue (n = 16)
Male gender, count (%) Age at operation, y (range) Height, cm Weight, kg Body Mass Index, kg/m2 Takeoff leg = right side, count (%) Takeoff leg = operated side, count (%)
Reduction of ankle dorsiflexion Difference in spontaneous plantar flexion Difference in calf circumference Static single-legged heel raise Thompson-Dougherty test Peak torque (dynamometer) Pain Subjective loss of power Ability to perform sports Sensitivity to meteorological changes Subjective overall assessment by patient Total
Intervention
P value*
Fibrin Glue (n = 16)
Plantaris (n = 15)
10.0
10.0
0.73
10.0
10.0
0.73
5.0
3.0
0.23
10.0
10.0
0.40
5.0
5.0
0.33
10.0
8.0
0.72
10.0 10.0
10.0 10.0
0.37 0.70
10.0 (n = 15)† 5.0
10.0 (n = 13)† 5.0
0.61 0.18
10.0
10.0
0.95
87
86
0.62
P value*
*Two-sided Mann Whitney U test for unpaired data. †One patient in the fibrin group and 2 patients in the plantaris group never performed sports before and after the Achilles tendon rupture.
TABLE 4 Prevalence of postoperative complications (count [%]) by intervention group, ascertained at the time of the longterm follow-up visit (N = 31)
Plantaris (n = 15)
13 (81)
11 (73)
.69
38 (28–67)
39 (16–73)
.91
173 78.5 25.4
173 78.0 26.6
.61 .50 .26
12 (75)
12 (80)
10 (63)
3 (20)
1.0 .03
*Two-sided Mann Whitney U test for continuous variables, Fisher’s exact test for proportions.
Complication
Pain at the rim of the shoe Hypertrophic scar Paresthesia Adhesions Delayed wound healing Thrombosis Infection Rerupture Total
Intervention Fibrin Glue (n = 16)
Plantaris (n = 15)
1 (6) 1 (6) 0 1 (6) 0 1 (6) 0 1 (6) 5 (31)
1 (7) 0 1 (7) 0 0 1 (7) 0 1 (7) 4 (27)
P value*
> .05 > .05 > .05 > .05 > .05 > .05 > .05 > .05 > .05
*Fisher’s exact test.
Comparison of Fibrin Glue to Suture Repair Results are compared in Tables 2 to 5. The clinical evaluation revealed a mean range of motion between maximal plantarflexion and dorsal extension of 52.5 in the fibrin group, and 55 in the augmented group (P = .56). The results 442
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of dynametric testing showed 45 for the fibrin group, and 46 for the augmented group (P = .71). In the fibrin group, a single patient reported a pain score of 2; in the augmented group, 1 patient reported a persistent pain score of 1. The remaining patients in both groups were pain-free.
TABLE 5 Median (range) values of isokinetic dynamometer results (N = 31) Fibrin Glue (n = 16) OP side Maximum peak torque 30 /sec (Nm) Maximum peak torque 120 /sec (Nm) Maximum peak torque 180 /sec (Nm) Maximum peak torque/ body weight 30 /sec (Nm/kg) Maximum peak torque/ body weight 120 /sec (Nm/kg) Maximum peak torque/ body weight 180 /sec (Nm/kg) Work per repetition 30 /sec (Nm) Work per repetition 120 /sec (Nm) Work per repetition 180 /sec (Nm) 30 /sec ankle with maximum peak torque ( ) 120 /sec Ankle with maximum peak torque ( ) 180 /sec Ankle with maximum peak torque ( ) Range of motion flexion ( ) Range of motion flexion + extension ( ) Fatigue index 180 /sec Total time 30 /sec Flexion/extension (sec) Total time 120 /sec Flexion/extension (sec) Total time 180 /sec Flexion/extension (sec)
Healthy
65 (19–99) 71 (16–95) P = .25 31.5 (11–64) 35 (12–57) P = .25 30 (14–47) 31 (19–47) P = .42 86 (27–113) 92 (24–125) P = .16 39 (15–75) 48 (18–66) P = .28 36 (18–57) 39 (24–54) P = .30 30 (5–62) 37 (7–57) P = .21 18 (4–42) 25 (11–43) P = .01 184 (100–330) 232 (100–540) P < .01 –3 (–17–3) –10 (–13–4) P = .54 –6 (–19–4) –5 (–14–6) P = .95 –12 (–22–(–3)) –8 (–21–2) P = .26 31 (12–42) 25 (13–48) P = .79 45 (29–61) 47 (37–69) P = .27 22.5 (–30–35) 6 (–19–28) P = .33 16 (11.2–22.4) 18.2 (11–25.8) P = .39 6.2 (4.5–21.6) 6.7 (5.2–20) P = .15 14.5 (11.8–19.3) 14.6 (12.8–19) P = .67
Plantaris (n = 15) OP side
P Value* (OP)
P Value* (Healthy)
.92
.66
.33
.41
.87
.89
.93
.48
.43
.71
.94
.53
.98
.61
.33
.81
.57
.94
.14
.06
.43
.23
.34
.94
.13
.59
.63
.75
.19
.26
.38
.78
.92
.85
.97
.41
Healthy
54 (28–107) 62 (27–98) P = .57 35 (16–50) 35 (26–50) P = .43 30 (16–45) 33 (16–43) P = .25 75 (30–143) 72 (36–131) P = .88 46.5 (21–66) 45 (30–63) P = .41 36 (21–60) 36 (21–57) P = .34 31 (9–50) 32 (9–49) P = .37 22 (5–37) 24 (19–37) P = .09 193 (134–389) 225.5 (134–397) P = .10 –9 (–21– (–1)) –3 (–14–13) P = .02 –7 (–15–2) 1 (–14–5) P < .01 –12 (–24–1) –8 (–19–1) P = .10 22 (4–34) 31 (12–38) P = .02 46 (34–58) 47.5 (35–64) P = .05 7 (–144–33) 15 (–10–31) P = .13 16.2 (12.2–20.3) 17 (12.8–23) P = .05 6.2 (5–7.5) 6.4 (5.7–8.5) P = .90 14.7 (12.1–18) 15.4 (13–18.4) P = .33
Abbreviations: OP side, operated side; Healthy, healthy side; Nm, Newton meter. *Two-sided Mann Whitney U test.
Comparison of Treated versus Healthy Side For both the fibrin glue and the augmented repair techniques, the operated side achieved similar results compared with the healthy side (Table 5). All of the comparisons showed no statistically significant differences after Bonferroni adjustment (Table 5). Discussion The treatment of acute Achilles tendon ruptures is widely discussed in the literature (4, 18, 20, 28–33). It has been argued that an anatomical reconstruction of ruptured Achilles tendons with fibrin glue is efficacious (11, 12, 34–36), and since the 1980s gluing with fibrin has been used as an
alternative to the more common suture technique for treating Achilles tendon ruptures. The positive influence of fibrin glue on tendon tissue healing has been demonstrated in experimental animal trials (34, 37–44). We hypothesized that repair of Achilles tendon ruptures with fibrin glue would achieve results comparable to repair using fibrin glue augmented with plantaris longus tendon. At the time of operation we found a plantaris longus tendon in 56.8% of our cases. This result agrees with findings in the literature (19, 21, 45). Four patients in the plantaris group (26.7%) had complications, as did 5 in the fibrin group (31.3%). These rates are higher than those of Paes et al (21), who had fewer complications in their plantaris group (11.9%). Further in contrast, though, we had no wound infection. VOLUME 48, NUMBER 4, JULY/AUGUST 2009
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One measure of the success of an Achilles tendon repair is the rerupture rate (4, 29). The average rerupture rate in the literature is 1.4% for operatively treated patients and 13.0% for conservatively treated patients (4, 29, 31). Paar et al (36) observed 1 rerupture after adequate trauma in 21 glued Achilles tendons, and Winter (46) reported 1 rerupture after adequate trauma in 52 glued Achilles tendons. Paes et al (21) reported 1 rerupture in 30 Achilles tendons augmented with the plantaris longus tendon, whereas Mayer et al. (19) observed no rerupture over a mean follow-up of 3.4 years. Seventeen of 23 patients were treated with a plaited plantaris longus tendon as suggested by Streli (24, 25). In keeping with the literature, in our study 1 patient in the plantaris group and 1 patient in the fibrin group experienced a rerupture after sustaining subsequent trauma. As another outcome measure, we used the modified Thermann score by Weber et al (28), which uses a scoring system of up to 100 possible points. We found no significant difference between the plantaris and the fibrin groups (P = .75). Paes et al (21) also found no significant difference between the Bunnell adaptation suture and the plantaris interlacing technique. But the authors preferred the latter because they recorded significantly fewer skin adhesions and achieved better cosmetic results owing to a pseudotendon sheath, which results from operative diversification of the plantaris tendon. Mayer et al (19) recorded 70% excellent results with the Trillat score. Twenty-three patients were included in the study; however, only 10 could be evaluated clinically and 7 by questionnaire. Kuskucu et al (47) found 75% excellent and 25% good results with the Thermann score in 32 glued Achilles tendon ruptures. The authors used neither additional suture material nor the plantaris longus tendon for augmentation. Furthermore, they referred to the limited operative approach when gluing with fibrin. In our experience, a larger approach is necessary for the plantaris interlacing technique, which has a higher risk of wound-healing disturbance. This was confirmed by Aktas et al (48). We propose the abandonment of the plantaris interlacing technique because we found no significant advantage in the augmented glued Achilles tendons. Zwipp et al (49) support this, stating that from their experience with 153 Achilles tendon ruptures one can abandon the primary augmentation technique in an acute Achilles tendon rupture. However, all Achilles tendons were reconstructed with a Bunnell plaiting suture in the opposite direction with 2–0 nontraumatic resorbable suture material and not with fibrin. Also, in their current concept review Popovic and Lemaire (31) found no evidence that a primary augmentation of an acute Achilles tendon rupture yields better results compared with a single end-to-end repair. This was also confirmed by other authors (18, 48, 50) who found no evidence for better results when the plantaris longus tendon was used for augmentation of an Achilles tendon repair. 444
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Winckler et al (51) pointed out that less suture material caused less strangulation of the ruptured Achilles tendon, so local circulation impairment to the tendon tissue could be avoided. The plantaris interlacing technique was efficient in certain patients with an increased amount of single tendon filaments in the rupture areas. In our opinion, plaiting the plantaris longus tendon with a plaiting forceps can cause additional trauma to the injured tendon ends, with local circulation impairment to the tendon tissue. We observed no statistically significant difference between the results of augmentation with plantaris longus tendon versus those without augmentation of glued Achilles tendons in an isokinetic force measurement. We agree with Ambacher et al (52), who see isokinetic testing as an objective and reproducible method of comparison that only tests isolated muscle groups. Therefore, a safe, predictive assessment for complex motion sequences in daily life and sport cannot be derived directly (12). The strength of this study is its long-term follow-up of 11.5 years, and the fact that we were able to include 77.5% of the original 40 patients who met our inclusion criteria after such a long interval since surgery. We also used a subjective patient satisfaction outcome measurement, which provides important information for surgeons dealing with patients who have suffered Achilles tendon rupture. We did not analyze the potential influence on outcome of either the surgeon of record or the alteration of the postoperative protocol, that is, converting to use of the vacuum brace system, and we did not have the data to analyze many variables at the time of the original surgery, which is a classic problem with retrospective cohort studies. Finally, we did not conduct inferential analyses beyond hypothesis testing for paired and unpaired data, and we did not conduct a sensitivity analysis to determine just how variables, such as smoking status or other comorbidities, could have influenced the results. The statistically equal modified Thermann scores, isokinetic force measurement results, and complication rates of patients in both groups suggest that augmentation of fibrin glue repair of acute Achilles tendon ruptures with the plantaris longus tendon is not necessary. We believe as well that fibrin glue is especially effective in the anatomical reconstruction of the tendon when the ruptured tendon fibers have a macroscopically ‘‘exploded’’ appearance (12). The results of this study, if not definitive, nevertheless can inform further investigation of augmenting fibrin glue repair of ruptured Achilles tendons with plantaris longus tendon through prospective cohort study or randomized controlled trial.
Acknowledgment We would like to thank Christopher Ritter, PhD for assistance and preparation of the manuscript.
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24. Streli R. Achillessehnennaht mit der Plantaris-longus-Sehne. Wien med Wochenschr 110:536–537, 1960. 25. Streli R. Achillessehnennaht mit der Plantarissehne. Klin Med 16: 305–312, 1961. 26. Gilcreest EL. Ruptures and tears of muscles and tendons of the lower extremity: report of fifteen cases. J Am Med Assoc 100:153–160, 1933. 27. Platt H. Observations on some tendon ruptures. BMJ 1:611–615, 1933. 28. Weber M, Niemann M, Lanz R, Mu¨ller T. Nonoperative treatment of acute rupture of the Achilles tendon. Results of a new protocol and comparison with operative treatment. Am J Sports Med 31:685–699, 2003. 29. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 21: 791–799, 1993. 30. Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AHN, Donell ST. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achilles. J of Bone Joint Surg Br 88:69–77, 2006. 31. Popovic N, Lemaire R. Diagnosis and treatment of acute ruptures of the Achilles tendon. Current concepts review. Acta Orthop Belg 65: 458–471, 1999. 32. Speck M, Klaue K. Early full weightbearing and functional treatment after surgical repair of acute Achilles tendon rupture. Am J Sports Med 26:789–793, 1998. 33. Van der Linden-van der Zwaag HMJ, Nelissen RGHH, Sintenie JB. Results of surgical versus non-surgical treatment of Achilles tendon rupture. Int Orthop 28:370–373, 2004. 34. Glu¨ckert K, Pesch HJ. Fibrinklebung bei Sehnenla¨sionen-Experimentelle Erfahrungen und klinische Aspekte. In Fibrinklebung, p 221, edited by J Scheele, Springer-Verlag, Berlin, 1984. 35. Haas F, Haibock H, Reindl P. Achillessehnenklebung mit Fibrin. Zentralbl Chir 112:99–104, 1997. 36. Paar O, Bernett P. Therapie der Achillessehnen-Ruptur beim Sportler. Vorteile der Fibrinklebung. Fortschr Med 22:1106–1108, 1984. 37. Blume M, Lauschke G. Tierexperimentelle Untersuchungen zur Wirksamkeit der Fibrinklebung bei der Versorgung von Achillessehnenrupturen. Beitr Orthop Traumatol 34:309–312, 1987. 38. Bo¨sch P, Hertz H, Lintner F, Novotny R. Beschleunigt das Fibrinklebesystem (FKS) die Heilungsvorga¨nge von Sehnengewebe? Arch Orthop Traumat Surg 98:305–310, 1981. 39. Haibo¨ck HF, Michalowski KA. Wie ist die Methode der operativen Versorgung von Achillessehnenrupturen mit Fibrinkleber zu beurteilen. Iatros Orthopa¨die 1:17–20, 1986. 40. Pneumaticos SG, Phd PCN, McGarvey WC, Mody DR, Trevino SG. The effects of early mobilization in the healing of Achilles tendon repair. J Foot Ankle Int 21:551–557, 2000. 41. Schlag G, Redl H. Fibrin sealant in orthopedic surgery. Clin Orthop 227:269–285, 1988. 42. Thermann H, Frerichs O, Biewener A, Krettek C. Healing of the Achilles tendon: an experimental study. Foot Ankle Int 22:478–483, 2001. 43. Thermann H, Frerichs O, Biewener A, Krettek C, Schandelmeier P. Die funktionelle Behandlung der frischen Achillessehnenruptur. Eine experimentelle biomechanische Untersuchung. Unfallchirurg 98: 507–513, 1995. 44. Lusardi DA, Cain JE Jr. The effect of fibrin sealant on the strength of tendon repair of full thickness tendon lacerations in the rabbit achilles tendon. J Foot Ankle Surg 33:443–447, 1994. 45. Incavo SJ, Alvarez RG, Trevino SG. Occurrence of the plantaris tendon in patients sustaining subcutaneous rupture of the Achilles tendon. J Foot Ankle Surg 8:110–111, 1987. 46. Winter U. Versorgung frischer Achillessehnenrupturen mit dem Fibrinkleber. Akt Traumatol 15:219–221, 1985.
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47. Kuskucu M, Mahirogullari M, Solakoglu C, Akmaz I, Rodop O, Kiral A, Kaplan H. Treatment of rupture of the Achilles tendon with fibrin sealant. J Foot Ankle Surg 26:826–831, 2005. 48. Aktas S, Kocaoglu B, Nalbantoglu U, Seyhan M, Guven O. End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures. J Foot Ankle Surg 46:336–340, 2007. 49. Zwipp H, Sudkamp N, Thermann H, Samek N. Die Achillessehnenruptur. 10-Jahresspa¨tergebnisse nach operativer Behandlung. Eine retrospective Studie. Unfallchirurg 92:554–559, 1989.
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50. Brade A. Verletzungen der Achillessehne und operative Therapie: Plantarisdurchflechtung oder Adaptationsnaht. Unfallheilkunde 80:73–76, 1977. 51. Winckler S, Neumann H, Reder U. Langzeitergebnisse nach Operation der Achillessehnenruptur. Akt Traumatol 21:64–69, 1991. 52. Ambacher T, Ku¨hn P, Schmidt R, Disselhorst-Klug C, Paar O. Kraftverha¨ltnisse und funktionelle Ergebnisse nach operativer Therapie der Achillessehnenruptur mittels Fibrinklebung. Zentralbl Chir 126: 989–994, 2001.
The Achilles tendon is the strongest and thickest tendon in the human body, and it takes its name from Achilles, the warrior of Homer’s Iliad. Ambrose Pare´ first described its rupture in 1575 (1), and the earliest publication on the condition dates from 1633. Frequently, acute ruptures of the Achilles tendon occur in men and in middle-aged individuals who are in their third or fourth decade of life, most commonly those participating in physically demanding work, sports, or leisure activities. About 30% of all sports-related tendon lesions are Achilles tendon ruptures (2, 3), and the left Achilles tendon is more frequently involved than the right (4, 5). Preexisting complaints in the region of the Achilles tendon are reported in about 10% of cases of Achilles tendon rupture. Use of steroids and fluoroquinolone antibiotics are thought by some to be etiological factors (4). The treatment of
Address correspondence to Bernd Hohendorff, MD, SRO AG Langenthal, St. Urbanstrasse 67, 4900 Langenthal, Switzerland. E-mail: bernd. [email protected]. 1 Senior Physician, Department of Orthopaedics and Traumatology, SRO AG Langenthal, Langenthal, Switzerland. 2 Assistant Physician, Department of Orthopaedics and Traumatology, SRO AG Langenthal, Langenthal, Switzerland. 3 Assistant Physician and Professional Statistician, MEM Research Center University of Berne, Berne, Switzerland. Financial Disclosure: None reported. Conflict of Interest: None reported. Copyright Ó 2009 by the American College of Foot and Ankle Surgeons 1067-2516/09/4804-0005$36.00/0 doi:10.1053/j.jfas.2009.04.005
Achilles tendon ruptures remains a controversial issue. Quenu and Stoinovitch (6) first proposed surgical reconstruction in 1929. Since the early 1980s, different suture techniques have been used to reapproximate the tendon, and the use of fibrin glue also has been available since that time. The idea of using clotting substances to support hemostasis in the treatment of wounds dates from 1909, when Bergel (7) described the clotting effect of fibrin powder. In 1940 Young and Medawar (8) reunited peripheral nerves with fibrin glue in an experimental setting. But inadequate fibrinogen and lack of antifibrinolytics reduced the stability of the clots, despite the unawareness, at that time, of factor XIII and its effects. In 1972, Matras et al (9) successfully used a special cryoprecipitate of highly concentrated fibrinogen with an enhanced factor XIII content for reuniting peripheral nerves in animal experiments. The introduction of aprotinin (bovine pancreatic trypsin inhibitor) to reduce hemorrhage during surgery ended the problems with fibrinolysis and fibrin degeneration when fibrin adhesives were used to reapproximate tissues (10). The putative advantage for the use of fibrin glue as a tissue adhesive for Achilles tendon repair is that it provides a less traumatic surgical technique that enables anatomical reconstruction of the tendon fibers while avoiding suture-caused ischemia or inexact adaptation of the ruptured tendon ends (11, 12). Different studies have described augmentation techniques with artificial material or autologous tissue for strengthening the reconstructed Achilles tendon (13–23). First use of the VOLUME 48, NUMBER 4, JULY/AUGUST 2009
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plantaris longus tendon as autologous suturing material has been attributed to Streli (24, 25), although this method was mentioned in earlier publications (26, 27). To date, we are not aware of studies that describe the results of Achilles tendon ruptures treated operatively with the fibrin glue Tissucol (Baxter International Inc., Deerfield, IL) augmented with plantaris longus tendon. At our hospital, operative treatment of acute Achilles tendon ruptures is favored. The purpose of this study was to compare long-term (>10 years) results of acute Achilles tendon ruptures treated operatively with fibrin adhesive versus gluing augmented with plantaris longus tendon. We hypothesized that repair of Achilles tendon ruptures with only fibrin glue would achieve results that were comparable to the results obtained by means of fibrin glue repair augmented with plantaris longus tendon. In addition, we wanted to determine how the operated side compared with the healthy (nonoperated) side in patients who had undergone repair of their ruptured Achilles tendon, long after the repair had taken place. Patients and Methods Study Cohort Patients were selected for participation in this study based on the following 3 inclusion criteria: (1) the patient was unable to plantarflex the ankle on the injured side at the time of the initial presentation, (2) the presence of a positive ThompsonDougherty test on initial examination, and (3) surgical repair of the ruptured Achilles tendon took place within 7 days of the initial traumatic event. Patients were excluded if the initial evaluation and treatment of the rupture was delayed beyond 7 days, or the etiology of the rupture was determined to be secondary to a chronic or degenerative process rather than acute traumatic overload of the Achilles tendon. Surgical Interventions and Aftercare A medial skin incision and careful dissection of the paratenon was used to inspect and repair the ruptured Achilles tendon. The ruptured tendon ends were brushed with a small skin retractor, after which the ankle was positioned in 20 to 30 of plantarflexion and the tendon fibers were anatomically reduced. Fibrin glue (Tissucol Duo S 1.0 mL, Baxter International Inc.) was then injected in layers to secure the reduced portions of the tendon in apposition. No suture was used in the fibrin group for Achilles tendon repair. A plantaris longus tendon was always used when it was available and was not ruptured as well. The repair with fibrin glue was augmented with plantaris tendon plaited in a figure of 8 and sutured with itself in the technique suggested by Streli (24, 25). The paratenon was sutured after completing the Achilles tendon repair. Before 1999, postoperative treatment lasted 8 weeks. A circular thigh cast with 30 knee flexion and ankle plantar440
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flexion that avoided disruption of the repaired Achilles tendon was applied for 3 weeks after acute operative swelling subsided, after which a non–weight-bearing short-leg cast was applied with the ankle in 15 of equinus for the next 2 weeks. Finally, a short-leg, neutral-position walking cast was applied for 3 additional weeks. In 1999, the postoperative treatment was changed to include use of the Vacuped (Oped, Cham, Switzerland) vacuum brace system with 30 equinus position for 3 weeks, then 15 for 2 weeks, followed by 3 weeks in neutral position. Full weight bearing was allowed after 5 weeks for all cases, when the equinus position was neutral. Follow-up Examination We invited all the patients we could locate to return for long-term follow-up examination. Respondents gave informed consent and the local review board approved this follow-up study. Patient histories concerning the rupture and preexisting complaints related to the Achilles tendon were obtained. Specific items included the type of trauma related to the rupture, and whether the injury occurred at work, while participating in sports, or during free-time activities. Patients were asked to rate their current pain level from 0 (no pain) to 10 (unbearable). Complications, if any, were also recorded, including data related to delayed wound healing, infection, thrombosis, rerupture, or revision operation. The follow-up clinical evaluation included the subjective report of pain at the rim of the shoe and/or paresthesia upon contact with the surgical site, objective assessment of scar tissue, the presence or absence of adhesion, and ankle range of motion. Further data were obtained using the Thermann Score as modified by Weber et al (28) (Table 1). Isokinetic testing, in which a body segment accelerates to achieve a preselected fixed speed against an accommodating resistance, also was performed on both lower extremities using a HUMAC NORM Model 770 dynamometer (Computer Sports Medicine, Inc., Stoughton, MA). Statistical Analyses For the statistical evaluation in this relatively small sample, only nonparametric methods were used for the comparisons between the groups. The fibrin and suture groups were compared with the 2-sided Mann Whitney U test for unpaired data. For the comparison between the operated and healthy sides, the 2-sided Wilcoxon signed ranks test was used to compare these paired data. Differences in proportions were analyzed using Fisher’s exact test. Bonferroni correction was used to adjust for multiple comparisons in regard to Thermann scores, complication rates, and isokinetic tests. A total of 93 tests were performed, and the significance level was set to a = 0.05. All of the statistical analyses were
conducted on a personal computer using SAS 9.1 (SAS Institute Inc, Cary, NC).
TABLE 1 Thermann score* modified by Weber et al. (28), ascertained at the time of long-term follow-up Outcome Reduction of ankle dorsiflexion None 5 10 >10 Reduction in spontaneous plantar flexion (prone) None 5 10 >10 Reduction in calf circumference None 1 cm 2 cm >2 cm Static single-legged heel raise 1 minute 10 seconds Barely possible Impossible Thompson-Dougherty test Negative Positive Peak torque as percentage of healthy side >95% 85% 75% 65% <65% Pain None Only with maximum exertion With moderate exertion With minimal exertion At rest None Subjective loss of power Minor loss on maximum exertion Minor loss on normal exertion Moderate loss on normal exertion Severe loss Ability to perform sports At pre-injury level Minimal restriction Moderate restriction Impossible Sensitivity to meteorological (barometric pressure) changes None Present Subjective overall assessment by patient Very good Good Moderate Fair Poor Total
Points
10 5 2 0 10 5 2 0 10 5 3 0 10 5 1 0 5 0 10 8 6 2 0 10 8 3 2 0 10 8 6 2 0 10 8 3 0 5 0 10 8 6 2 0 100
*Maximum score = 100 points; very good $90, good $80 <90, moderate $70 <80, fair $60 <70, poor <60 points.
Results Demographic Characteristics of the Cohort A total of 44 Achilles tendon ruptures were treated operatively with fibrin glue between October 1987 and December 1999. Of these, 40 patients (33 men, 7 women) met our criteria for inclusion in this investigation. The remaining 4 were excluded because of delayed presentation after trauma, or degenerative or chronic Achilles tendon rupture. The median age of the patients at the time of operation was 38 years (range 25–67) in the fibrin group and 39 (range 16–80) in the augmented group (P = .58). In the fibrin group (n = 18), 8 patients were operated within 1 day of their rupture, and 10 underwent surgical repair before the seventh day following the injury. In the augmented group (n = 22), 11 patients were operated within the first day following their rupture, and 11 underwent surgical repair before the seventh day. Delayed operation beyond the first posttraumatic day was caused either by late presentation to the emergency department, or the need to attend to other medical and scheduling issues before operative intervention. At operation we found a plantaris longus tendon in 56.8% of our cases. The same 2 experienced surgeons performed all of the procedures.
Characteristics of the Cohort at Long-term Follow-up In summer 2006, the 40 patients were invited to a follow-up examination. Three of the 40 patients had died, and 1 could not be found. Another 5 patients were unable to attend the followup examination because of lack of time, although all 5 claimed to be very satisfied with the results of their operation. We therefore carried out a long-term follow-up examination on 31 (77.5%) patients who had had their ruptured Achilles tendon repaired, 16 with fibrin glue and 15 with fibrin glue augmented with plantaris longus tendon. A flow diagram of the selection process for the study sample is shown in Figure 1. Table 2 compares gender, age at operation, height, weight, body mass index, and take-off leg results for the 2 groups at longterm follow-up. In the fibrin group, trauma was sustained during activities related to work (n = 1), leisure (n = 5), or sports (n = 10). In the augmented group, trauma was related to leisure (n = 4) or sports activities (n = 11). In the fibrin group, 9 ruptures occurred on the right side, and 7 on the left; 2 patients had previous complaints of Achilles tendon pain before they ruptured the tendon. In the augmented group, 4 ruptures were on the right side, 11 on the left; 1 patient in the augmented group had complaints of Achilles tendon pain before the rupture. VOLUME 48, NUMBER 4, JULY/AUGUST 2009
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TABLE 3 Median Thermann score, modified by Weber et al. (28), ascertained at the time of the long-term follow-up visit (N = 31)
Achilles tendon ruptures treated (Oct 1987 – Dec 1999): n = 44
Outcome Excluded: n = 4
Patients included at baseline: n = 40
Fibrin group:
Augmented group:
n = 18
n = 22
Lost to Follow-up: n=2 not found: n = 1 no time: n = 1
Lost to Follow-up: n=7 died: n = 3 no time: n = 4
Follow-up:
Follow-up:
n = 16
n = 15
FIGURE 1 Selection process of the study sample.
TABLE 2 Demographic data by intervention group, ascertained at the time of the long-term follow-up visit (N = 31) Variable
Intervention Fibrin Glue (n = 16)
Male gender, count (%) Age at operation, y (range) Height, cm Weight, kg Body Mass Index, kg/m2 Takeoff leg = right side, count (%) Takeoff leg = operated side, count (%)
Reduction of ankle dorsiflexion Difference in spontaneous plantar flexion Difference in calf circumference Static single-legged heel raise Thompson-Dougherty test Peak torque (dynamometer) Pain Subjective loss of power Ability to perform sports Sensitivity to meteorological changes Subjective overall assessment by patient Total
Intervention
P value*
Fibrin Glue (n = 16)
Plantaris (n = 15)
10.0
10.0
0.73
10.0
10.0
0.73
5.0
3.0
0.23
10.0
10.0
0.40
5.0
5.0
0.33
10.0
8.0
0.72
10.0 10.0
10.0 10.0
0.37 0.70
10.0 (n = 15)† 5.0
10.0 (n = 13)† 5.0
0.61 0.18
10.0
10.0
0.95
87
86
0.62
P value*
*Two-sided Mann Whitney U test for unpaired data. †One patient in the fibrin group and 2 patients in the plantaris group never performed sports before and after the Achilles tendon rupture.
TABLE 4 Prevalence of postoperative complications (count [%]) by intervention group, ascertained at the time of the longterm follow-up visit (N = 31)
Plantaris (n = 15)
13 (81)
11 (73)
.69
38 (28–67)
39 (16–73)
.91
173 78.5 25.4
173 78.0 26.6
.61 .50 .26
12 (75)
12 (80)
10 (63)
3 (20)
1.0 .03
*Two-sided Mann Whitney U test for continuous variables, Fisher’s exact test for proportions.
Complication
Pain at the rim of the shoe Hypertrophic scar Paresthesia Adhesions Delayed wound healing Thrombosis Infection Rerupture Total
Intervention Fibrin Glue (n = 16)
Plantaris (n = 15)
1 (6) 1 (6) 0 1 (6) 0 1 (6) 0 1 (6) 5 (31)
1 (7) 0 1 (7) 0 0 1 (7) 0 1 (7) 4 (27)
P value*
> .05 > .05 > .05 > .05 > .05 > .05 > .05 > .05 > .05
*Fisher’s exact test.
Comparison of Fibrin Glue to Suture Repair Results are compared in Tables 2 to 5. The clinical evaluation revealed a mean range of motion between maximal plantarflexion and dorsal extension of 52.5 in the fibrin group, and 55 in the augmented group (P = .56). The results 442
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of dynametric testing showed 45 for the fibrin group, and 46 for the augmented group (P = .71). In the fibrin group, a single patient reported a pain score of 2; in the augmented group, 1 patient reported a persistent pain score of 1. The remaining patients in both groups were pain-free.
TABLE 5 Median (range) values of isokinetic dynamometer results (N = 31) Fibrin Glue (n = 16) OP side Maximum peak torque 30 /sec (Nm) Maximum peak torque 120 /sec (Nm) Maximum peak torque 180 /sec (Nm) Maximum peak torque/ body weight 30 /sec (Nm/kg) Maximum peak torque/ body weight 120 /sec (Nm/kg) Maximum peak torque/ body weight 180 /sec (Nm/kg) Work per repetition 30 /sec (Nm) Work per repetition 120 /sec (Nm) Work per repetition 180 /sec (Nm) 30 /sec ankle with maximum peak torque ( ) 120 /sec Ankle with maximum peak torque ( ) 180 /sec Ankle with maximum peak torque ( ) Range of motion flexion ( ) Range of motion flexion + extension ( ) Fatigue index 180 /sec Total time 30 /sec Flexion/extension (sec) Total time 120 /sec Flexion/extension (sec) Total time 180 /sec Flexion/extension (sec)
Healthy
65 (19–99) 71 (16–95) P = .25 31.5 (11–64) 35 (12–57) P = .25 30 (14–47) 31 (19–47) P = .42 86 (27–113) 92 (24–125) P = .16 39 (15–75) 48 (18–66) P = .28 36 (18–57) 39 (24–54) P = .30 30 (5–62) 37 (7–57) P = .21 18 (4–42) 25 (11–43) P = .01 184 (100–330) 232 (100–540) P < .01 –3 (–17–3) –10 (–13–4) P = .54 –6 (–19–4) –5 (–14–6) P = .95 –12 (–22–(–3)) –8 (–21–2) P = .26 31 (12–42) 25 (13–48) P = .79 45 (29–61) 47 (37–69) P = .27 22.5 (–30–35) 6 (–19–28) P = .33 16 (11.2–22.4) 18.2 (11–25.8) P = .39 6.2 (4.5–21.6) 6.7 (5.2–20) P = .15 14.5 (11.8–19.3) 14.6 (12.8–19) P = .67
Plantaris (n = 15) OP side
P Value* (OP)
P Value* (Healthy)
.92
.66
.33
.41
.87
.89
.93
.48
.43
.71
.94
.53
.98
.61
.33
.81
.57
.94
.14
.06
.43
.23
.34
.94
.13
.59
.63
.75
.19
.26
.38
.78
.92
.85
.97
.41
Healthy
54 (28–107) 62 (27–98) P = .57 35 (16–50) 35 (26–50) P = .43 30 (16–45) 33 (16–43) P = .25 75 (30–143) 72 (36–131) P = .88 46.5 (21–66) 45 (30–63) P = .41 36 (21–60) 36 (21–57) P = .34 31 (9–50) 32 (9–49) P = .37 22 (5–37) 24 (19–37) P = .09 193 (134–389) 225.5 (134–397) P = .10 –9 (–21– (–1)) –3 (–14–13) P = .02 –7 (–15–2) 1 (–14–5) P < .01 –12 (–24–1) –8 (–19–1) P = .10 22 (4–34) 31 (12–38) P = .02 46 (34–58) 47.5 (35–64) P = .05 7 (–144–33) 15 (–10–31) P = .13 16.2 (12.2–20.3) 17 (12.8–23) P = .05 6.2 (5–7.5) 6.4 (5.7–8.5) P = .90 14.7 (12.1–18) 15.4 (13–18.4) P = .33
Abbreviations: OP side, operated side; Healthy, healthy side; Nm, Newton meter. *Two-sided Mann Whitney U test.
Comparison of Treated versus Healthy Side For both the fibrin glue and the augmented repair techniques, the operated side achieved similar results compared with the healthy side (Table 5). All of the comparisons showed no statistically significant differences after Bonferroni adjustment (Table 5). Discussion The treatment of acute Achilles tendon ruptures is widely discussed in the literature (4, 18, 20, 28–33). It has been argued that an anatomical reconstruction of ruptured Achilles tendons with fibrin glue is efficacious (11, 12, 34–36), and since the 1980s gluing with fibrin has been used as an
alternative to the more common suture technique for treating Achilles tendon ruptures. The positive influence of fibrin glue on tendon tissue healing has been demonstrated in experimental animal trials (34, 37–44). We hypothesized that repair of Achilles tendon ruptures with fibrin glue would achieve results comparable to repair using fibrin glue augmented with plantaris longus tendon. At the time of operation we found a plantaris longus tendon in 56.8% of our cases. This result agrees with findings in the literature (19, 21, 45). Four patients in the plantaris group (26.7%) had complications, as did 5 in the fibrin group (31.3%). These rates are higher than those of Paes et al (21), who had fewer complications in their plantaris group (11.9%). Further in contrast, though, we had no wound infection. VOLUME 48, NUMBER 4, JULY/AUGUST 2009
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One measure of the success of an Achilles tendon repair is the rerupture rate (4, 29). The average rerupture rate in the literature is 1.4% for operatively treated patients and 13.0% for conservatively treated patients (4, 29, 31). Paar et al (36) observed 1 rerupture after adequate trauma in 21 glued Achilles tendons, and Winter (46) reported 1 rerupture after adequate trauma in 52 glued Achilles tendons. Paes et al (21) reported 1 rerupture in 30 Achilles tendons augmented with the plantaris longus tendon, whereas Mayer et al. (19) observed no rerupture over a mean follow-up of 3.4 years. Seventeen of 23 patients were treated with a plaited plantaris longus tendon as suggested by Streli (24, 25). In keeping with the literature, in our study 1 patient in the plantaris group and 1 patient in the fibrin group experienced a rerupture after sustaining subsequent trauma. As another outcome measure, we used the modified Thermann score by Weber et al (28), which uses a scoring system of up to 100 possible points. We found no significant difference between the plantaris and the fibrin groups (P = .75). Paes et al (21) also found no significant difference between the Bunnell adaptation suture and the plantaris interlacing technique. But the authors preferred the latter because they recorded significantly fewer skin adhesions and achieved better cosmetic results owing to a pseudotendon sheath, which results from operative diversification of the plantaris tendon. Mayer et al (19) recorded 70% excellent results with the Trillat score. Twenty-three patients were included in the study; however, only 10 could be evaluated clinically and 7 by questionnaire. Kuskucu et al (47) found 75% excellent and 25% good results with the Thermann score in 32 glued Achilles tendon ruptures. The authors used neither additional suture material nor the plantaris longus tendon for augmentation. Furthermore, they referred to the limited operative approach when gluing with fibrin. In our experience, a larger approach is necessary for the plantaris interlacing technique, which has a higher risk of wound-healing disturbance. This was confirmed by Aktas et al (48). We propose the abandonment of the plantaris interlacing technique because we found no significant advantage in the augmented glued Achilles tendons. Zwipp et al (49) support this, stating that from their experience with 153 Achilles tendon ruptures one can abandon the primary augmentation technique in an acute Achilles tendon rupture. However, all Achilles tendons were reconstructed with a Bunnell plaiting suture in the opposite direction with 2–0 nontraumatic resorbable suture material and not with fibrin. Also, in their current concept review Popovic and Lemaire (31) found no evidence that a primary augmentation of an acute Achilles tendon rupture yields better results compared with a single end-to-end repair. This was also confirmed by other authors (18, 48, 50) who found no evidence for better results when the plantaris longus tendon was used for augmentation of an Achilles tendon repair. 444
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Winckler et al (51) pointed out that less suture material caused less strangulation of the ruptured Achilles tendon, so local circulation impairment to the tendon tissue could be avoided. The plantaris interlacing technique was efficient in certain patients with an increased amount of single tendon filaments in the rupture areas. In our opinion, plaiting the plantaris longus tendon with a plaiting forceps can cause additional trauma to the injured tendon ends, with local circulation impairment to the tendon tissue. We observed no statistically significant difference between the results of augmentation with plantaris longus tendon versus those without augmentation of glued Achilles tendons in an isokinetic force measurement. We agree with Ambacher et al (52), who see isokinetic testing as an objective and reproducible method of comparison that only tests isolated muscle groups. Therefore, a safe, predictive assessment for complex motion sequences in daily life and sport cannot be derived directly (12). The strength of this study is its long-term follow-up of 11.5 years, and the fact that we were able to include 77.5% of the original 40 patients who met our inclusion criteria after such a long interval since surgery. We also used a subjective patient satisfaction outcome measurement, which provides important information for surgeons dealing with patients who have suffered Achilles tendon rupture. We did not analyze the potential influence on outcome of either the surgeon of record or the alteration of the postoperative protocol, that is, converting to use of the vacuum brace system, and we did not have the data to analyze many variables at the time of the original surgery, which is a classic problem with retrospective cohort studies. Finally, we did not conduct inferential analyses beyond hypothesis testing for paired and unpaired data, and we did not conduct a sensitivity analysis to determine just how variables, such as smoking status or other comorbidities, could have influenced the results. The statistically equal modified Thermann scores, isokinetic force measurement results, and complication rates of patients in both groups suggest that augmentation of fibrin glue repair of acute Achilles tendon ruptures with the plantaris longus tendon is not necessary. We believe as well that fibrin glue is especially effective in the anatomical reconstruction of the tendon when the ruptured tendon fibers have a macroscopically ‘‘exploded’’ appearance (12). The results of this study, if not definitive, nevertheless can inform further investigation of augmenting fibrin glue repair of ruptured Achilles tendons with plantaris longus tendon through prospective cohort study or randomized controlled trial.
Acknowledgment We would like to thank Christopher Ritter, PhD for assistance and preparation of the manuscript.
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