Percutaneous Achilles Repair

Monika Volesky, M.D., FRCSC
Montreal, QC

The optimal treatment for acute Achilles tendon ruptures remains controversial, and recent advances in both operative and nonoperative treatments have not resolved this debate. Advances in operative management have included evolving suture techniques, increased suture strength, as well as methods of percutaneous and mini-open repair. Although many studies show definite advantages of open over nonoperative repair, historically high wound complication rates and infections reported in open repairs have served as an impetus to try less invasive procedures. Percutaneous repair was first described by Ma and Griffith1 in 1977 to take advantage of the benefits of both open and nonoperative treatment techniques.

Ma and Griffith's published technique, involved passing a Bunnell stitch through a series of stab incisions made along the medial and lateral aspects of the tendon without exposing the tear site. While their results in 18 patients were overwhelmingly positive with no infections and no re-ruptures, ensuing investigations were more troubling with complications of re-rupture and sural nerve injury2.

A recent Level 1 evidence meta-analysis of twelve randomized, controlled trials involving 800 patients addressing treatment of acute Achilles tendon ruptures by Khan et al.3 touts the advantages of percutaneous over open repair4. Overall, they found that the rerupture rate was lower in open operative repair (3.5%) than in nonoperative management (12.6%). In studies comparing open and percutaneous repairs, re-rupture rates for open techniques were 4.3% versus 2.1% in the percutaneous group. Khan et al. also established that open repair had a higher risk of other complications (34.1%) compared to nonoperative treatment. The rates of these complications such as infection, adhesions, and nerve injury was 26.1% in the open group and 8.3% in the percutaneous group, in studies directly comparing these two types of repairs. These results parallel the findings of other meta-analyses by Wong et al.5 and Bhandari et al.6.

Detractors of percutaneous repair claim that biomechanically this method may not allow for optimal suture technique, since laboratory studies have shown the non-strangulating locking loop described by Krackow et al. to have the highest pull-out strength. Modified percutaneous suture techniques, as well as mini-open methods of repair are showing promise in biomechanical testing. New devices such as the Achillon (Integra Life Sciences Corporation, Plainsboro, NJ) allow the tendon itself to become the only site of tissue attachment for the suture by guiding percutaneously placed sutures to lie fully within the paratenon, thus theoretically protecting the sural nerve. While the surgical technique is beyond the scope of this article, the Achillon is simple to use, has fared well in laboratory testing and early independent clinical results confirm that the technique offers patients a safe operative procedure for repair of acute Achilles tendon ruptures that allows early active rehabilitation7. To address the issue of nerve injury in percutaneous repairs, some authors have advocated a mini-open technique including retraction of or limited exposure of the sural nerve in order to avoid incorporating it into the repair.

The goal of any treatment method is to optimize patients' functional outcome while minimizing complications. Recent studies looking at isokinetic plantarflexion strength and endurance after Achilles repair confirm a slightly better result when testing the uninvolved side. However, there were no statistically significant differences for these parameters among the subjects that were treated either percutaneously or by an open surgery. Cretnik et al. showed no differences in functional outcome between the two groups using validated outcome scores8. Interestingly, few studies identify patients at risk of wound complications in open repairs. Bruggeman et al.9 found that tobacco use, diabetes, corticosteroid use, and female sex increased the risk of wound infections, while Pajala et al.10 added age and rupture with everyday activities to this list.

In summary, open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of re-rupture compared with nonoperative treatment but has the drawback of a significantly higher risk of other complications, including wound infection. The rate of wound complications and cosmetic results can be improved by performing the surgery percutaneously, especially if attention is paid to protecting the sural nerve. Since the functional results after percutaneous repair are comparable to that of open techniques, choosing to perform percutaneous or mini-open Achilles tendon repair in the setting of an acute rupture is well supported, especially in patients at increased risk of wound problems.

References

  1. Ma G.W., Griffith T.G. Percutaneous repair of acute closed ruptured achilles tendon: a new technique. Clin Orthop Relat Res 1977(128):247-55.
  2. Chiodo C.P., Wilson MG. Current concepts review: acute ruptures of the achilles tendon. Foot Ankle Int 2006;27(4):305-13.
  3. Khan R.J., Fick D., Keogh A., Crawford J., Brammar T., Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87(10):2202-10.
  4. 4. Khan R.J., Fick D., Brammar T.J., Crawford J., Parker M.J. Interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev 2004(3):CD003674.
  5. Wong J., Barrass V., Maffulli N. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med 2002;30(4):565-75.
  6. Bhandari M., Guyatt G.H., Siddiqui F., et al. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res 2002(400):190-200.
  7. Calder J.D., Saxby T.S. Independent evaluation of a recently described Achilles tendon repair technique. Foot Ankle Int 2006;27(2):93-6.
  8. Cretnik A., Kosanovic M., Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med 2005;33(9):1369-79.
  9. Bruggeman N., Turner N., Dahm D., al. e. Wound complications after open Achilles tendon repair: an analysis of risk factors. Clin Orthop 2004;427:63-6.
  10. Pajala A., Kangas J., Ohtonen P., Leppilahti J. Rerupture and deep infection following treatment of total Achilles tendon rupture. J Bone Joint Surg Am 2002;84-A(11):2016-21.

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