Rates of Acute and Delayed Achilles Repair

Category: Sports, Trauma Introduction/Purpose: The need for repair of the ruptured achilles tendon has been discussed extensively in recent literature. A landmark paper in 2010 (Willits JBJS) outlined that the re-rupture rates were similar in surgical and non surgically treated Achilles tendon ruptures. However concern has to be raised as to the strength of the muscle tendon complex if the tendon is too long, potentially increasing the rate of late repair. This paper analyses the rate of acute achilles tendon repair and delayed repair before and after the 2010 publication of the Willits paper. Methods: Using the published billings from the Province of British Columbia, the rates per year of surgical repair of achilles tendon and delayed repair were determined. The population of British Columbia has increased over the years from 3.9 million in 1997 to 4.7 million in 2016. The rates of acute and chronic surgery were plotted prior to 2010, and since 2010. The rates were fitted against time using a linear and binomial plot. The rates in the years before and after 2010 were compared with ANOVA and the change of rate in time compared with Pearson’s correlation. Results: The rate of acute repair increased from 271 repairs in 1997 to over 400 repairs per year in 2009. The rate of acute repair has since dropped to just over 300 repairs per year. This is reflected in the enclosed binomial plot. There was a significant increase until 2010 (p<0.001), and a significant decrease since 2010 p<0.05). An average of 374 repairs per year (95% CI 349 to 398) were performed before 2010, decreasing to 328 since (95% CI 294 to 360), p<0.05. The rate of late repair has increased from 48 per year (CI 40 to 56) to 80 (CI 70 to 91) since 2010. The rate of late repair increased both prior to (r2 prior to 2010 .5, p<0.01) and since 2010. Conclusion: The landmark 2010 paper has resulted in a reduction of acute repair. However the increase in late repair is concerning and indicates that the muscle tendon weakness observed in the 2010 paper on strength testing at 1 year review in the non surgical group may be causing an increased rate of late repair. Further evaluation and development of both surgical and non surgical technique is required if the need for late repair is going to be avoided that likely reflects poor patient outcomes

Patient Reported Outcomes Following Revision Ankle Arthrodesis for Ankle Fusion Non-Union

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Ankle arthrodesis (AA) has, for many years, been considered the gold standard procedure for the surgical treatment of end stage ankle arthritis. Non-union following AA surgery is a devastating complication which subsequently requires revision surgery. However, data on outcomes including patient reported outcome measures (PROMs) following revision ankle arthrodesis (RAA) after failed AA is lacking. The aim of this study is to assess the outcome of RAA for symptomatic non-union after AA including PROMs. Methods: Prospectively collected data from a multicenter database of ankle arthritis surgery was analyzed. Demographic data and PROMs including Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) health survey were collected at regular intervals. Surgeries were performed by six fellowship-trained foot and ankle surgeons between January 2003 and July 2015. 336 primary AA cases were identified, of which 27 (8%) underwent revision for symptomatic AA non-union. Results: Mean follow-up of 27 AA non-union cases was 5.3 years (2-10). There were 16 (59%) males and 11 (41%) females, with a mean age of 62 years (44 - 81) and a mean BMI of 32 (26.5 – 45), respectively. At index AA, 12 (44%) cases were performed arthroscopically. Twenty-three (84%) AA non-union patients were actively smoking pre- and post-operatively, and 15 (56%) were diabetic. Overall union-rate following RAA was 85% (23/27). For RAA the pre-operative mean AOS score of 64.9 (38.8-81.5) improved to 49.1 (24.1-73) at latest follow-up. SF-36 PCS score improved from 27.2 (21.3 – 38.3) to 33.3 (19.1-54.2) and SF-36 MCS score improved from 41.2 (17.5-60.9) to 46.2 (29.3-65.9). Overall complication rate of RAA was 22%, with a re-operation rate of 15%. Conclusion: Revision ankle arthrodesis (RAA) for ankle fusion non-union resulted in a successful fusion of the ankle in 85% of patients with modest improvement in AOS and SF-36 scores. Indeed, even after successful RAA, patients report pain and disability levels comparable to that reported by primary AA patients pre-operatively. Additionally, complication and re-operation rates of RAA are high. This data emphasizes on the importance of achieving a primary fusion in AA. The presented patient reported outcomes may help the treating surgeon to counsel patients prior to RAA surgery to better set their expectations