SLR - February 2023 - Niral A. Patel, DPM, MS
Title: Absorbable versus nonabsorbable sutures for the Krackow suture repair of acute Achilles tendon rupture: a prospective randomized controlled trialReference: Park YH, Kim W, Choi JW, Kim HJ. Absorbable versus nonabsorbable sutures for the Krackow suture repair of acute Achilles tendon rupture: a prospective randomized controlled trial. Bone Joint J. 2022 Aug;104-B(8):938-945.
Level of Evidence: 1
Scientific Literature Review
Reviewed By: Niral A. Patel, DPM, MS
Residency Program: Ascension St. Vincent Indianapolis, IN
Podiatric Relevance: A condition evaluated and managed by foot and ankle surgeons is Achilles tendon rupture. Surgical re-approximation of a ruptured Achilles tendon with suture material is a common procedure performed by podiatric surgeons. The selection of suture material is a critical component of the procedure. Therefore, this study aimed to prospectively compare the use of braided absorbable polyglactin sutures and braided non-absorbable polyethylene terephthalate sutures for the Krackow suture repair of ATR.
Methods: A level I prospective randomized controlled trial using 1:1 randomization was performed for all patients who required surgical repair for acute Achilles tendon ruptures. A total of 40 patients were included in the trial. 20 patients were assigned to the No. 2 absorbable braided polyglactin suture group and 20 patients were assigned to the No. 2 nonabsorbable braided polyethylene terephthalate suture group. This was a single-blinded study as patients did not know which group they were assigned. Achilles tendon repair required two units of suture per patient. The absorbable suture costs $10.54 per unit, while the nonabsorbable suture costs $6.43 per unit.
Intervention: All procedures were performed by the same surgeon. A midline incision was made over the rupture site. After meticulous dissection, a Krackow suture technique was performed in a two-stranded single configuration, with three locking loops made along each side of the tendon. After applying the core suture, the repair site of the tendon was augmented with interrupted circumferential sutures using the No. 1 sizes of each suture material.
Rehabilitation: After surgery, a short leg splint in 20° plantar flexion was applied and retained for 2 weeks. Patients were instructed to perform non-weight-bearing mobilization using crutches. After 2 weeks, patients were transitioned to weight-bearing activity in a CAM boot, set at 20° plantar flexion. At six weeks, the CAM boot was set to neutral and ankle motion exercise was initiated. At 9 weeks, the CAM boot was increased to 10° dorsiflexion. Patients now reduced the use of crutches and wore the CAM boot only during daytime activities. At 12 weeks, patients stopped wearing the CAM boot and were instructed to perform a home exercise program. At six months, patients were allowed progressive training in non-competitive sporting activities. Return to daily activity was started from 9-12 months.
Results: The Achilles tendon Total Rupture Score (ATRS) was used as the primary outcome measure. For secondary outcome measures, the visual analog scale for pain (VAS pain), EuroQoL five-dimension health questionnaire (EQ- 5D) which takes into account mobility, self-care, usual activities, pain/discomfort, & anxiety/depression, and isokinetic muscle strength were assessed. The ATRS, VAS pain, and EQ-5D scores were assessed 6 and 12 months after surgery. At 6 & 12 months, the mean ATRS was respectively 69.5 and 88.1 in the absorbable group and 61.9 and 89.8 in the nonabsorbable group. At 6 & 12 months, the mean VAS for pain was respectively 29 and 6.6 in the absorbable group, and 28.9 and 5.7 in the nonabsorbable group. At 6 & 12 months, the mean EQ-5D score was respectively 1.58 and 1.22 in the absorbable group and respectively 1.52 and 1.16 in the nonabsorbable group. Isokinetic muscle strength was assessed 3 and 6 months after surgery. Specifically, peak torque deficit and total work of 30 & 180 degrees/second angle speed were evaluated. The median values nor values at 25th & 75th percentile differed significantly in the absorbable or nonabsorbable group for peak torque deficit (30°/s and 180°/s) or total work (30°/s and 180°/s) at 3 months or 6 months.
Conclusions: Assessment of isokinetic muscle strength at 3 and 6 months after surgery showed that the plantar flexion strength deficits did not differ significantly between the two groups with respect to the peak torque and total work at test speeds of 30°/s and 180°/s. The ATRS, VAS pain, and EQ-5D scores did not differ significantly between the two groups at 6 and 12 months after surgery. In conclusion, the primary findings of the study are that the patient-reported outcome measures (PROMs) and isokinetic plantar flexion strength did not differ between the absorbable and the nonabsorbable suture groups. Surgeons may comfortably use either absorbable or nonabsorbable sutures as the clinical outcomes of absorbable sutures are not inferior to those of nonabsorbable sutures for ATR repair. The authors cannot rule out the possibility that one suture may exhibit a greater incidence of load-to-failure leading to re-rupture as re-rupture rates were not compared in the study. Additionally, infection postoperative complications were also not compared in the study. As the present study complements the limitations of previous studies on absorbable and nonabsorbable sutures, the results provide useful clinical information for surgeons considering the choice of suture materials for ATR.