Achilles Tendon Rupture: Open Repair

Mohit Bhandari M.D., MSc, FRCSC
Division of Orthopaedic Surgery,McMaster University
Hamilton, ON

What's the Problem?
Rupture of the Achilles tendon is both a serious injury and one of the most common tendinous lesions occurring in 18 per 100 000 persons1. These injuries have historically been treated by conservative methods (cast immobilization, bandaging)2. Since the mid-1900's, however, surgical repair of the ruptured tendon has become popular2.

Despite the recent popularity of surgical intervention, the choice of surgical repair versus conservative cast treatment of acute Achilles tendon ruptures remains controversial. Observational studies have attempted to clarify the role of surgery or casting in the treatment of Achilles tendon ruptures3.

Why is Open Repair Superior to Nonoperative Management?
Open repair of Achilles tendon ruptures significantly reduces the risk of re-rupture. A meta-analysis of randomized trials (n= 5 studies, 336 patients) found a significantly reduced risk of re-rupture of open versus conservative treatment (3.6% vs 10.6%, respectively; relative risk=0.41, 95% confidence interval, 0.17 ‑0.99, p=0.05; homogeneity p value=0.31)3 See Table 1. This data suggests that for every 14 patients treated with surgery, one re-rupture can prevented (NNT=1/0.07=14).

Table 1

Outcome Measure

Total Patients

Number of Events Surgery

Conservative

Relative Risk (95% CI)

P Value

Homogeneity P value

Re-rupture

448

7/225(3.1%)

29/223(13%)

0.32 (0.14-0.71)

0.005

0.41

Infection

421

10/211(4.7%)

0/210(0%)

4.62 (1.20-17.79)

0.03

0.34

Return to Function

421

144/211(71%)

133/210(63%)

1.04 (0.86-1.27)

0.68

0.42

Spontaneous Complaints

448

43/225(19%)

56/223(25%)

0.83 (0.43-1.57)

0.56

0.54

adapted from reference 3

What's the Downside of Open Repair?
Wound infection is the primary concern with open repair. In a meta-analysis, infections rates from open repairs varied from approximately 4% to over 20%. The relative risk of infection with surgical repair was 5.2 times greater than cast treatment (95% confidence interval. 1.17-23.04, p=0.03; homogeneity pvalue=0.53)3.

What Are the Principles of an Open Surgical Technique?
The patient is placed in the prone position with both prepped feet dangling from the end of the table. In the Trendelenburg position, the feet receive less blood flow. A posteromedial incision is preferred and its length is variable, ranging between six to ten cm. The paratenon is identified and longitudinally cut. The ruptured ends of the tendon are identified and usually have a frayed' appearance. The ends of the tendon are approximated and secured with non-absorbable suture via a Krackow or Bunnell stitch4. Prior to tying the suture ends, the tendon's dynamic resting tension is optimized by comparing it with the control side. A circumferential stitch further strengthens the repair site. The paratenon is closed, subcutaneous tissues approximated and the wound closed.

Are Less Invasive Surgical Techniques Better?
The answer remains debatable. The ideal situation is a less invasive procedure that limits infection rates and provides the strength of repair comparable to open repairs (with the resultant decrease in re-rupture risk).

Early reports with percutaneous repair reported inferior results when compared with open repair. However, recently randomized trials suggest decreased complications with this approach (relative risk, 0.35; 95% confidence interval, 0.13- 0.94)4. The upper bound of the confidence approaches no difference, suggesting the need for larger trials to definitively resolve the relative benefit of less invasive surgery.

References

  1. Leppilahti J., Puranen J., Orava S. Incidence of achilles tendon rupture. Acta Orthopaedica Scandinavica. 1996; 67:277-279.
  2. Maffulli N. Rupture of the achilles tendon. J Bone Joint Surg 1999; 81A: 1019-1036.
  3. Bhandari M., Guyatt G.H., Siddiqui F., Morrow F., Busse J., Leighton R.K., Sprague S., Schemitsch E.H. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 2002 Jul;(400):190-200
  4. Sterling Atkinson T., Easley M. The Expert Opinion: Complete Ruptures of the Achilles Tendon Medscape Orthopaedics & Sports Medicine 5(3), 2001.

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