Pedro Diniz1,2,3,4, Jácome Pacheco5, Ricardo M Fernandes6, Hélder Pereira7,8,9, Frederico Castelo Ferreira10,11, Gino M M J Kerkhoffs12,13,14. 1. Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela 501, 2775-028, Parede, Portugal. pedro.diniz@scml.pt. 2. Department of Bioengineering, iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal. pedro.diniz@scml.pt. 3. , Fisiogaspar, Lisboa, Portugal. pedro.diniz@scml.pt. 4. Associate Laboratory i4HB - Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal. pedro.diniz@scml.pt. 5. Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela 501, 2775-028, Parede, Portugal. 6. Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisboa, Portugal. 7. Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal. 8. Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia, Madrid, Spain. 9. University of Minho ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal. 10. Department of Bioengineering, iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal. 11. Associate Laboratory i4HB - Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal. 12. Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands. 13. Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands. 14. Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands.
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.
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.
Authors: Thomas O Clanton; C Thomas Haytmanek; Brady T Williams; David M Civitarese; Travis Lee Turnbull; Matthew B Massey; Coen Abel Wijdicks; Robert F LaPrade Journal: Am J Sports Med Date: 2015-06-10 Impact factor: 6.202