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Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

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.

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Abbreviations

ATR:

Achilles tendon rupture

MFSS:

Multifilament stainless steel

N:

Newtons

NMA:

Network meta-analysis

PARS:

Percutaneous Achilles Repair System

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

SUCRA:

Surface under the cumulative ranking curve

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Acknowledgements

The authors acknowledge the financial support from Fundação para a Ciência e a Tecnologia (FCT-MEC), Portugal, through the research unit iBB [UIDB/04565/2020].

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Hospital de Sant’Ana, Rua de Benguela 501, 2775-028, Parede, Portugal

    Pedro Diniz & Jácome Pacheco

  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 & Frederico Castelo Ferreira

  3. Fisiogaspar, Lisboa, Portugal

    Pedro Diniz

  4. Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisboa, Portugal

    Ricardo M. Fernandes

  5. Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal

    Hélder Pereira

  6. Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia, Madrid, Spain

    Hélder Pereira

  7. University of Minho ICVS/3B’s-PT Government Associate Laboratory, Braga/Guimarães, Portugal

    Hélder Pereira

  8. Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands

    Gino M. M. J. Kerkhoffs

  9. Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands

    Gino M. M. J. Kerkhoffs

  10. Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands

    Gino M. M. J. Kerkhoffs

  11. Associate Laboratory i4HB - Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal

    Pedro Diniz & Frederico Castelo Ferreira

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Contributions

PD designed the systematic review protocol, screened and selected studies, extracted and analyzed data, performed network meta-analysis and drafted the manuscript. JP screened and selected studies and extracted data. RMF designed the systematic review protocol, provided guidance in the quantitative synthesis and revised the manuscript. HP and FCF revised the manuscript. GK designed the systematic review protocol, supervised the selection of studies and revised the manuscript. All authors read and approved the final manuscript.

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Correspondence to Pedro Diniz.

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Diniz, P., Pacheco, J., Fernandes, R.M. et al. Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta-analysis of human cadaveric studies. Knee Surg Sports Traumatol Arthrosc 31, 1644–1657 (2023). https://doi.org/10.1007/s00167-021-06613-9

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