Compara've Bio-Mechanical Study of Acute Tendon of Achilles Repair between Krackow and Uchiyama Technique in an Ex Vivo Porcine Model

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Compara've Bio-Mechanical Study of Acute Tendon of Achilles Repair between Krackow and Uchiyama Technique in an Ex Vivo Porcine Model Mary Rose Gonzales, MD, Marikina City,

1 Compara've Bio-Mechanical Study of Acute Tendon of Achilles Repair between Krackow and Uchiyama Technique in an Ex Vivo Porcine Model Mary Rose Gonzales, MD, Marikina City, PHILIPPINES Kris'ne R. Italia, MD, Quezon City, Manila, PHILIPPINES Jose Raul C. Canlas, MD, FPOA, Mun'nlupa, Metro Manila, PHILIPPINES Richard Rotor, MD, Quezon City,, PHILIPPINES

2 Disclosure Mary Rose Gonzales, MD I have no financial conflicts to disclose Objec've This study compared the biomechanical property of krackow and uchiyama tendon repair technique and noted its mode of failure in an acute tendon rupture in an ex vivo porcine model

Introduc'on In 2009, Japanese orthopedic surgeons headed by Uchiyama conducted a study from May 2000 to April 2004 that u'lized a modified technique for repair of achilles tendon ruptures.

3 Introduc'on In 2009, Japanese orthopedic surgeons headed by Uchiyama conducted a study from May 2000 to April 2004 that u'lized a modified technique for repair of achilles tendon ruptures. This modified technique and early rehabilita'on allowed early weight bearing and early return to daily ac'vi'es and sports. Allowed strong repair stability and subsequent early weight bearing and range of mo'on exercises evaluated a newly modified method of repair and a unified rehabilita'on protocol to allow early weight- bearing and early return to daily ac'vi'es Uchiyama E, Nomura A, Takeda Y et al (2007). A modified opera'on for Achilles tendon ruptures. American journal of sports medicine.

Materials and Methodology 20 10 10 Twenty porcine ﬂexor digitorum tendons from the hind leg were harvested within 6 hours aher death of the animal.

Harvested tendons were randomly assigned to each of the 2 groups, with 10 tendons per group.

A single inves'gator performed the harvest, prepara'on and repair of all tendons. Sadoghi P, Rosso C, Valderrabano V et al (2012).

4 Materials and Methodology Twenty porcine ﬂexor digitorum tendons from the hind leg were harvested within 6 hours aher death of the animal. These were wrapped in saline-soaked gauze then refrigerated at 4 C aher removal of extraneous muscle 'ssues with a maximum storage 'me of 12 hours. Harvested tendons were randomly assigned to each of the 2 groups, with 10 tendons per group.a scalpel was used to transect each of the tendons transversely at the mid-substance, immediately preceding the repair. A single inves'gator performed the harvest, prepara'on and repair of all tendons. Sadoghi P, Rosso C, Valderrabano V et al (2012). Ini'al Achilles tendon repair strength synthesized biomechanical data from 196 cadaver repairs. Interna'onal orthopedics. 12: Tio Cuison J, Tablante E (2017). Ex vivo biomechanical analysis of barbed suture tenorraphy in a porcine model. Presented in Asia-paciﬁc knee arthroscopy and sports medicine society summit Seoul, Korea. April 28, Watson T, Jurist K, Yang K et al (1995). The strength of Achilles tendon repair: an in vitro study of the biomechanical behavior in human cadaver tendons. Foot and ankle interna'onal 16 (4): Uchiyama E, Nomura A, Takeda Y et al (2007). A modiﬁed opera'on for Achilles tendon ruptures. American journal of sports medicine.

5 Materials and Methodology For the first group, Using a doublestrand Krackow technique, four locking loops were spaced 5 mm from each other, 1 cm from the proximal end of the tendon. For the Uchiyama technique, each tendon end was divided into bundles approximately 5 mm wide - 2 proximal and 2 distal. The reconstruc'on was completed by gathering each bundle by Bunnell-like sutures. Each bundle was pulled lightly and fixed to the other end of the tendon in a linear fashion. Sadoghi P, Rosso C, Valderrabano V et al (2012). Ini'al Achilles tendon repair strength synthesized biomechanical data from 196 cadaver repairs. Interna'onal orthopedics. 12: Tio Cuison J, Tablante E (2017). Ex vivo biomechanical analysis of barbed suture tenorraphy in a porcine model. Presented in Asia-pacific knee arthroscopy and sports medicine society summit Seoul, Korea. April 28, Watson T, Jurist K, Yang K et al (1995). The strength of Achilles tendon repair: an in vitro study of the biomechanical behavior in human cadaver tendons. Foot and ankle interna'onal 16 (4): Uchiyama E, Nomura A, Takeda Y et al (2007). A modified opera'on for Achilles tendon ruptures. American journal of sports medicine.

Materials and Methodology Biomechanical tes'ng was conducted by a single civil engineer using a mechanical universal tes'ng machine with each end of a sample tendon secured using metal clamps.

6 Materials and Methodology Biomechanical tes'ng was conducted by a single civil engineer using a mechanical universal tes'ng machine with each end of a sample tendon secured using metal clamps. Load to failure test was done with longitudinal trac'on at an advancement rate of 0.85 mm/s. Failure is deﬁned as suture breakage and pullthrough or pull-out, un'l no further increase in the load registered on the machine, indica'ng that the ul'mate load has been reached. Ul'mate load to failure was measured. Mode of failure was recorded, whether at the suture or tendon substance. Tio Cuison J, Tablante E (2017). Ex vivo biomechanical analysis of barbed suture tenorraphy in a porcine model. Presented in Asia-paciﬁc knee arthroscopy and sports medicine society summit Seoul, Korea. April 28, 2017.

Results Krackow repair [119.18N ± 37.4] Uchiyama repair [112.98 ± 32.06] Mode of failure Suture breakage (p=0.

7 Results Krackow repair [119.18N ± 37.4] Uchiyama repair [ ± 32.06] Mode of failure Suture breakage (p=0.34) T-test (SPSS 2017 ) Table of Load to failure (Newtons) of porcine tendons repaired by Krackow and Uchiyama Technique

8 Discussion Biomechanical systema'c review of repair in cadaveric human Achilles tendons a defini've recommenda'on on the most op'mal repair technique s'll cannot be made due to subject heterogeneity and varied methodology support the wide use of a double bundle Krackow suture technique u'lizing non-absorbable braided sutures as repair op'on for acute Achilles tendon rupture Sadoghi P, Rosso C, Vavken P (2012). Ini'al Achilles tendon repair strength synthesized biomechanical data from 196 cadaver repairs. Interna'onal orthopedics. 36:

9 Discussion Early mobiliza'on is encouraged as early as 2 to 4 weeks Immobilized tendon sutures lose 50% of their ini'al strength within the first week due to tenomalacia at the suture-tendon junc'on Early full weight bearing is believed to increase the risk of rerupture and thus the longer immobiliza'on period Uchiyama E, Nomura A, Takeda Y et al (2007). A modified opera'on for Achilles tendon ruptures. American journal of sports medicine. Clemente A, Bergamin F, Surace C et al (2015). Barbed suture vs conven'onal tenorrhaphy: biomechanical analysis in an animal model. Journal of Orthopaedic Traumatology.

10 Discussion Krackow Postopera1ve Management Uchiyama 6 weeks Dura'on of cas'ng 2 weeks 2 weeks Start of weight bearing 1 week Others 92 % Return to pre-injury ROM at 17 weeks Early weight bearing on the operated leg quicker return to daily ac'vi'es or sports earlier func'onal recovery trains the muscles on the operated side and prevents ar'cular car'lage deteriora'on Uchiyama E, Nomura A, Takeda Y et al (2007). A modified opera'on for Achilles tendon ruptures. American journal of sports medicine. American associa'on of orthopedic surgeons (2009). The diagnosis and treatment of acute Achilles tendon rupture: guideline and evidence report. Wu Z, Hua Y, Li H et al (2015). Biomechanical comparison of three methods for distal Achilles tendon reconstruc'on. Knee surgery and sports traumatology and arthroscopy. 23:

11 Discussion Early passive and especially ac've rehabilita'on programs have been shown to prevent ini'al weakening at the repair site by improving tendon nutri'on, healing and remodeling Controlled mobiliza'on aher the inflammatory phase which is approximately 1 week aher injury, enhances the quality of healing tendons by s'mula'ng fibroblast prolifera'on and collagen realignment Uchiyama E, Nomura A, Takeda Y et al (2007). A modified opera'on for Achilles tendon ruptures. American journal of sports medicine. Clemente A, Bergamin F, Surace C et al (2015). Barbed suture vs conven'onal tenorrhaphy: biomechanical analysis in an animal model. Journal of Orthopaedic Traumatology. Wang, J (2006). Mechanobiology of tendon. Journal of biomechanics 39:

12 Discussion Krackow Repair Uchiyama Ethibond 2 Type of suture Ethibond Number of core sutures 8 A 50% increase in strength to failure would be expected by increasing the number of crossing strands by 50% 12 core repair using a 2-0 non absorbable suture was stronger than a 6 core repair using a 2 non absorbable suture Huffard B, O Loughlin P, Wright, T et al (2008). Achilles tendon repair: achillon system vs. krackow suture: An anatomic in vitro biomechanical study. Clinical biomechanics 23: Backus J, Marchet D, Sleue E (2016). The effect of suture caliber and number of core strands on repair of acute Achilles ruptures using a mini-open repair: a biomechanics study. American orthopedics foot and ankle society.

13 Conclusion Uchiyama suture technique may be an alterna've to open repair of acute tendon of Achilles rupture With similar maximum load to failure, this may facilitate earlier range of mo'on for both Uchiyama and Krackow techniques of less than 2 weeks

14 Limita'ons Being an ex vivo biomechanical study the injury was created using a sharp scalpel rather than the degenera've tendon 'ssue associated with clinical rupture tendon repair was also done at 'me zero from injury may oversimplify Achilles tendon repair postopera've rehabilita'on Data be gathered is limited to ul'mate load to failure and may not be comparable to hypothesized earlier range of mo'on and weight bearing aher surgery

15 Recommenda'ons To inves'gate other biomechanical proper'es cyclic loading tendon gapping In vivo studies may also be done to inves'gate other proper'es of the Uchiyama technique greater surface contact smaller caliber sutures

16 References Uchiyama E, Nomura A, Takeda Y et al (2007). A modified opera'on for Achilles tendon ruptures. American journal of sports medicine. Sadoghi P, Rosso C, Valderrabano V et al (2012). Ini'al Achilles tendon repair strength synthesized biomechanical data from 196 cadaver repairs. Interna'onal orthopedics. 12: Tio Cuison J, Tablante E (2017). Ex vivo biomechanical analysis of barbed suture tenorraphy in a porcine model. Presented in Asia-pacific knee arthroscopy and sports medicine society summit Seoul, Korea. April 28, Watson T, Jurist K, Yang K et al (1995). The strength of Achilles tendon repair: an in vitro study of the biomechanical behavior in human cadaver tendons. Foot and ankle interna'onal 16 (4): Uchiyama E, Nomura A, Takeda Y et al (2007). A modified opera'on for Achilles tendon ruptures. American journal of sports medicine. Clemente A, Bergamin F, Surace C et al (2015). Barbed suture vs conven'onal tenorrhaphy: biomechanical analysis in an animal model. Journal of Orthopaedic Traumatology. Wang, J (2006). Mechanobiology of tendon. Journal of biomechanics 39: Huffard B, O Loughlin P, Wright, T et al (2008). Achilles tendon repair: achillon system vs. krackow suture: An anatomic in vitro biomechanical study. Clinical biomechanics 23: Backus J, Marchet D, Sleue E (2016). The effect of suture caliber and number of core strands on repair of acute Achilles ruptures using a mini-open repair: a biomechanics study. American orthopedics foot and ankle society.

Biomechanical Head-to-Head Comparison of 2 Sutures and the Giftbox vs Bunnell Techniques for Midsubstance Achilles Tendon Ruptures

Biomechanical Head-to-Head Comparison of 2 Sutures and the Giftbox vs Bunnell Techniques for Midsubstance Achilles Tendon Ruptures Rufus Van Dyke MD, Roman Trimba MD, Greg Gould BS, Sejul Chaudary BS,