SLR - March 2023 - Sukhranjan Nijjar, DPM
Title: Synthetic Graft Augmentation Is Safe and Effective for the Repair of Acute Achilles Tendon Rupture in Patients With Preexsiting TendinopathyReference: Haroun HK, Abd Elrahman AA, Morsi A. Synthetic Graft Augmentation Is Safe and Effective for the Repair of Acute Achilles Tendon Rupture in Patients With Preexisting Tendinopathy. Arthrosc Sports Med Rehabil. 2022 Nov 14;4(6)
Level of Evidence: IV
Reviewed by: Sukhranjan Nijjar, DPM
Residency Program: Kaiser San Francisco Bay Area Foot and Ankle – Oakland, CA
Podiatric Relevance: The Achilles tendon is the strongest and thickest tendon in the human body. Ruptures of this substantial structure have considerable consequences for patients. Although recent literature supports non-operative management, there are certain instances in which surgical intervention is necessary. In such cases, there is a debate as to whether exogenous or endogenous materials may help further aid in the repair of the tendon. The aim of this study is to determine whether the usage of inlay polypropylene mesh augmentation in Achilles’ tendon repair of patients with tendinopathy prior to rupture would lead to increased stability of the repair construct, allowing early return to preinjury activity level.
Methods: This therapeutic case series consisted of thirteen patients with tendinopathy prerupture that underwent surgical repair of the Achilles tendon with polypropylene mesh augmentation. Prior to surgery, patients were found to have non-opposing tendon ends on plantarflexion, determined either clinically or through ultrasonography. Surgically, the tendon stumps were split longitudinally, with placement of a 10 cm polypropylene mesh applied in an inlay fashion, which was then secured across the repair site utilizing a no. 2 Ethibond. This construct was reinforced with a Krakow stitch configuration and distally secured to the calcaneus. Post-operative protocol was as follows: two weeks of non-weightbearing in short leg cast in gravity equinus, followed by protected weightbearing in walking boot with a 2cm heel lift for an additional two weeks, transitioning to weight bearing as tolerated at neutral for four weeks, and removal of the boot at eight weeks. Post-operative follow-up was an average of 38 months (range 32-56 months). The AOFAS score, ATRS scores, and single heel raise were used to assess functional and clinical outcomes.
Results: In all thirteen patients, 8 male and 5 female, with an average age of 52 years (range 49-56 years), there was no rerupture of the Achilles tendon, with full return to plantarflexion strength. Average time for return to preinjury activity level was 16 weeks (range 14-18 weeks), with all patients being able to perform single heel raise that was comparable to the contralateral side. The average post-operative AOFAS score was 92.2, with a standard deviation of ± 2.2. The ATRS scores prior to rupture and post-operatively at final follow up were 88.5 and 89.2, respectively, with a standard deviation of ± 2.2. There were no foreign body reactions or other complications reported.
Conclusions: Ultimately, this study demonstrates favorable outcomes for inlay polypropylene mesh augmentation of Achilles tendon repair, which resulted in early return to baseline activity in patients with preexisting tendinopathy. However, the small sample size of thirteen patients is inadequate to establish an all-encompassing and definitive method of treatment for this pathology. Moreover, there is a lack of any control group or comparative studies. Despite these limitations, this technique may have some potential application for acute Achilles’ tendon rupture with pre-existing tendinopathy. Hence, additional randomized clinical trials which are sufficiently powered would be needed prior to routine augmentation of acute Achilles tendon repair with a polypropylene mesh.