Kirk A. McCullough, MD1; Christopher M. Shaw, MD1; and Robert B. Anderson, MD2
Tears of the Achilles tendon in professional athletes are an infrequent yet devastating injury. Historical studies have demonstrated not only a poor rate of return to competitive play but have also noted significant declines in performance for those able to return. While classic treatment of these injuries in the competitive athlete has been an open, locked suture repair, this article reports on a consecutive series of professional football athletes who underwent mini-open repair. All athletes returned to professional football, with seven out of nine (78%) returning to National Football League (NFL) competition. Average return to play was 273 days (8.9 months), with one athlete returning at 166 days (5.4 months). There have been no reruptures and no sural nerve or wound healing complications. Although limited in number currently, mini-open repair in NFL athletes has allowed successful return to competitive play with no reruptures and a trend toward faster return to play compared with historical open repair outcomes. (Journal of Surgical Orthopaedic Advances 23(4):179-183, 2014)
Tears of the Achilles tendon are an infrequent yet devastating injury to the athlete ( 1-3). They occur most often in middle-age (30- to 40-year-old) males with a reported annual rate of acute ruptures on the order of 18.2 to 37.3 per 100,000 (4, 5), with basketball being the most common sporting activity involved (6). Because of literature supporting a faster rerum to sport participation and a lower risk of rerupture compared with nonoperative treatment (2), operative intervention with open locking suture repair has been the mainstay of treatment in the athletic patient population (2, 7-9). Despite utilizing this management strategy, retrospective studies on both National Basketball Association (I) and National Football League (NFL) (3) athletes have demonstrated a significant impact on postinjury return to play and player performance even in those able to return. In their retrospective, web-based review of 31 NFL players surgically treated for Achilles tears from 1997 to 2002, Parekh et al. identified that 36% of these athletes were unable to return to play and that those who did return to play experienced a 50% drop in performance from preparticipation levels (3). Given concerns regarding potential wound healing issues with standard open treatment, the development of minimally invasive techniques has been entertained as a means of surgically approximating the tendon ends to restore the muscle-tendon unit while minimizing disruption of the paratenon and other overlying soft tissue to facilitate healing (I 0). However, additional studies have documented that mini-open devices, such as the Achillon device (Integra Life Sciences Corporation, Plainsboro, New Jersey), have not been without their associated risks, as sural nerve injury has been reported not too infrequently (II). Additionally, biomechanical concerns with these devices and their suture fixation constructs have left doubts regarding the ability to utilize an accelerated rehabilitation protocol while maintaining the integrity of the muscle-tendon unit, leaving most clinicians hesitant to use mini-open techniques in the competitive athlete patient population (12). To date, there is limited evidence regarding utilization of mini-open Achilles fixation in the elite athlete, and there are no known reports in the American professional football athlete. Furthermore, since the Percutaneous Achilles Repair System (PARS, Arthrex, Naples, Florida) was first introduced in 20 I 0, no published clinical studies currently exist in the medical literature documenting the efficacy of this device and its use in the United States population.
The purpose of this study is to report on the use of PARS mini-open repair in a consecutive series of professional football athletes. This article evaluates not only the efficacy of this treatment as it relates to risk of complications, including rerupture, sural nerve injury, and wound healing, but also sport-specific outcomes, including return to play, in this consecutive series cohort. In addition to an overview of the surgical technique employed, the postoperative regimen utilized in these athletes is outlined.
After obtaining institutional review board approval, a retrospective review of a consecutive series of NFL athletes treated by the senior author (RBA) for noninsertional rupture of the Achilles tendon using the PARS device was performed. Initial repairs using the PARS system were started in 2012 and repairs performed through 2013 to allow for a minimum follow-up time of 9 months were included in the study. Patient demographics including age, position played, NFL experience and seasons played, time to surgery, and time to return to competitive play (if applicable) were recorded. Statistical analysis primarily consisted of descriptive statistics.
All Achilles repairs were performed by the senior author (RBA) at a single institution and utilized the PARS system (see Fig. I). Once general anesthesia was induced, a nonsterile tourniquet was placed on the thigh before placing the patient in a prone position. The level of the Achilles tendon disruption was palpated and a 2.0- to 2.5-cm horizontal incision was made I em proximal to the disruption. The paratenon was encountered and, if not already disrupted, was incised in line with the skin incision. The sural nerve was protected. Local seroma and hematoma were then evacuated, and the area of disruption was irrigated and cleaned. An Allis clamp was used to grasp the proximal stump, and any adhesions present between the tendon and paratenon were released with care not to violate the paratenon sheath proximally. The PARS jig was then placed within the paratenon, and sutures were then passed through the tendon tissue with at least one locking and two transverse stitches in the tendon stump (see Fig. 2.) Additionally, conversion of the transverse suture closest to the tear to a locking stitch construct was performed whenever possible, as described within the PARS technique guide. The distal stump was then prepared in the same fashion with the PARS system. Under direct visualization and with the foot maximally plantarflexed, the tendon stumps were approximated and secured in place, tying and cutting knots in sequential order as directed. The wound was then thoroughly irrigated and closed in layered fashion with separate deep closure of the paratenon, followed by interrupted suture closure of the skin (see Fig. 3). A sterile soft dressing and a well-padded modified Jones splint were then placed with the foot plantarflexed to 20o.
Non-weight-bearing activity with elevation of the operative limb over the first 2 weeks was encouraged to minimize swelling. At 2 weeks, the wound was inspected and early active motion was allowed, avoiding dorsiflexion. The limb was protected in plantarflexion with a removable splint or boot. Sutures were removed at 3 weeks. The patient was gradually allowed to dorsiflex the ankle to neutral. Progressive partial to full weight-bearing activities in a boot with heel lifts ensued at 4 to 5 weeks once the foot could be dorsiflexed to neutral. At 8 to 10 weeks postoperatively, regular shoe wear with a heel lift was allowed that gradually reduced in height over the subsequent 3 to 4 weeks as tolerated. Our preference was to limit passive and active dorsiflexion to neutral at 12 weeks. Off-loaded running in a pool or antigravity environment (e.g., AlterG treadmill), proprioception, and calf-strengthening exercises were allowed after 1 2 weeks postoperatively, followed by full field running at 4 months postoperatively. Return to football-related activities was allowed at 5 months postoperatively as tolerated. Ultimately, return to competition was limited to timing of the injury and schedule of competitive preseason and regular season activities, in addition to the player’s preinjury contract status.
Nine NFL athletes were identified within this retrospective review. Demographics for the athletes included are listed in Table I.
The average age at the time of injury in this patient population was 25.6 years. The average years of NFL experience before the injury year was three seasons. The average time from injury to surgery was 5.6 days. All athletes were progressed through the postoperative rehabilitation regimen as described above. The average return to competitive play was 273 days (8.9 months). The earliest return to play was 166 days (5.4 months). Regarding NFL-specific return to play, seven of nine (78%) returned to NFL play. Of the two players who did not return, one returned to professional football play in the Canadian Football League and the other in the Indoor Football League. Regarding surgery-related complications, no postoperative wound issues or sural nerve injuries were noted, and no tendon retears occurred with return to football activities.
While surgical management remains a mainstay of treatment in Achilles tendon ruptures within the competitive athlete population, debate regarding the optimal technique for repair of these injuries continues. Despite the historical assertions by Bradley and Tibone that open repair is recommended for all athletes who cannot afford the chance of rerupture, the use of modified percutaneous and mini-open techniques has gained favor in recent years involving Achilles tendon repair in this patient population (13). In their 201 1 study, Maffulli et al. identified 1 7 elite athletes treated with percutaneous fixation methods for Achilles rupture (2). While two of these athletes dealt with a superficial infection of their surgical wound during their recovery period, all were able to return to play, at an average of 4.8 months following surgery, with no reported reruptures. Orr et al., evaluating a consecutive series of 15 male active-duty service members treated for acute Achilles tendon rupture with the Achillon device, noted no subsequent rerupture and return to full duty with only one instance of delayed wound healing and one patient who developed subsequent noninsertional Achilles tendinopathy that was managed nonoperatively (14). As with the current study, each of these separate clinical study cohorts demonstrate the ability of a percutaneous and mini-open technique to allow for return to function for these high-demand patients.
Recent biomechanical studies have lent further credenceto the utilization of mini-open techniques in comparison with the standard open treatment of Achilles tendon tears. Despite prior biomechanical data demonstrating the superior strength of the Krackow locking suture construct ( 15), in their 2008 in vitro study of the Achillon device compared with open repair Krackow suture constructs, Huffard et al. demonstrated the superior maximum tensile loading strength to failure compared with traditional Krackow suture repair ( 16). This study was then followed up by a study by Heitman et al. that, in comparing Achillon to Krackow suture constructs, provided further evidence of the overall biomechanical strength of the Achillon construct compared with its open Krackow counterpart ( 17). Despite these similarities, however, gap formation with cyclic loading of the nonlocked loop construct of the Achillon technique compared with the Krackow construct remained a clinical concern, especially in light of the demonstrated benefit of initiating early clinical rehabilitation protocols. Ultimately, the introduction of the PARS device and its locked suture construct provided a mini-open solution to this biomechanical concern. In their recent 2014 in vitro study, Demetracopoulos et al. demonstrated not only a higher load to failure with the PARS suture constructs compared with Achillon constructs, but also demonstrated a statistically significant greater number of loading cycles required to generate gap formation between the tendon ends (12). As such, this enhanced biomechanical understanding of the PARS construct utilized in this study further supports its clinical application and validates its success in our patient population.
Concerning our specific clinical findings, because the study of NFL Achilles tendon injuries from 1997 to 2002 by Parekh et al. stands as the only other published evidence within the medical literature regarding this pathology and its effect on professional American football play, it is important to evaluate the differences betweenthese respective studies’ findings (3). While the return to play rate frequently quoted from Parekh et al.’ s study reflects that nearly one third of these athletes will never return to play, we demonstrated a 78% return to play rate for the nine players treated within our study. If the analysis is focused only on established players and removes the two undrafted free agents injured within their rookie year, our return to play rate is 100%. Clearly, return to play is dependent on multiple factors beyond physical recovery from injury, but this is an important consideration when interpreting and extrapolating this type of data to other players’ chance of return to play function when sustaining an Achilles tear. While the average age in the Parekh study was 29, our average age was 25.7, which might in part explain why our study subjects demonstrated an increased return to play rate. We also determined an average return to competitive play of 8.9 months, compared with an average of 11 months within the Parekh study. This fact is certainly aided by the return of one of our patients at 5.4 months postsurgery, which at the time was noted by multiple sports media markets as the fastest known return to competitive play for an American football player following Achilles repair. An additional important consideration regarding return to play data reporting is timing of the injury as it relates to the competitive season. For most players, if the injury occurs during preseason or regular season competition, although they may be cleared for football activity at 5 months, they will not have a chance to return to that competitive level until the following preseason games are scheduled. As expected, this will skew return to play data to a longer time frame than what should be anticipated from a functional recovery perspective when counseling the athlete, coaches, and management. Therefore, it may be more important to emphasize timing of release to football activity and cases with early return to play as the more reliable time frames of return to sport. Finally, compared with the 5-year period of data collection within the Parekh study, we are certainly limited by the fact that our collection period was under 2 years, because the PARS device was not used in these patients before March 201 2. Furthermore, we were unable to perform a pre- and postinjury performance analysis because of low numbers of observations and limited time since return to play. This analysis will undoubtedly be an imp01tant one to perform in the future to determine any potential efficacy of miniopen compared with standard open repair in this patient population.
Although numbers so far are limited, our study demonstrates that mini-open repair of noninsertional Achilles tears utilizing the PARS device is a safe and effective option in the elite NFL athlete population, with no reruptures, no sural nerve or wound complications, and with a potential trend toward faster return to sport activity compared with historical open repair outcomes. While previous studies have documented the decreased wound complication risk with minimally invasive repair compared with open repair, further comparative studies are needed to confirm if the mini-open approach affords other benefits to the athlete, such as faster return to play, compared with open operative techniques, while not exposing them to increased risks such as sural nerve injury.Apr-24-2015 Blog