Percutaneous Versus Open Repair of Achilles Tendon Ruptures

SLR-March 2014-Kristy Golden

Reference: Panagiotis Karabinas, Ioannis Benetos, Kalliopo Lampropoulou, Pavlos Romoudis, Andreas Mavrogenis, John Vlamis. Percutaneous Versus Open Repair of Acute Achilles Tendon Ruptures. European Journal of Orthopedic Surgical Traumatology 2013; 591 (13) 1350-1357.

 

Scientific Literature Review

Reviewed by: Kristy A. Golden, DPM
Residency Program: Inova Fairfax Hospital
 

Podiatric Relevance: Controversy still exists when it comes to the best treatment of acute Achilles tendon ruptures. With the re-rupture rate of closed treatment noted as high as12-17 percent and the wound infection rate in open repair upwards of 21 percent, surgeons are still looking for the safest way to treat acute Achilles tendon ruptures. This study by Panagiotis et al, aims to compare the outcomes of the two common operative techniques for Achilles tendon repair: open vs. percutaneous.

Methods:  Thirty four patients with complete acute (less than 48h) Achilles tendon ruptures and a tendinous gap of less than 3 cm were included in the study. All ruptures occurred in the watershed area, 2-6 cm proximal to the insertion on the calcaneus. Fifteen patients had open repair and nineteen had percutaneous repair. The average follow up was 22 months and no patients were lost from the study. The open repair was performed through a 10 cm incision located 1 cm medial to the edge of the tendon. A Krackow technique was utilized with No. 1 non-absorbable suture. The percutaneous repair was performed using a long Keith needle and No.1 non-absorbable suture. Five stab incisions were created, two medial to the tendon and three lateral. The needle was inserted in the proximal lateralincision and passed transversely through the proximal segment of tendon andexiting the proximal medial incision. The needle was then passed obliquely to the distal lateral incision and then transversely through the distal segment. Finally, the suture ends were advanced the middle lateral incision and tied together. Both groups, open and percutaneous, were rehabilitated with three weeks of immobilization in a non weight bearing cast in maximum plantarflexion followed by progressively less plantarflexion and gradual increase in weight bearing over the next three-four weeks. The outcomes of wound healing complications, ankle range of motion, return to work, activity level, weight bearing, and subjective assessment were recorded. Fisher’s exact test and student’s t test were used to statistically analyze the data.
 

Results: No significant difference in any of the variables was observed between the two groups. Tendon healing was observed in all patients at seven-nine weeks. All patients were full weight bearing at the eighth week. AOFAS score was 98 for open and 95 for percutaneous repairs. Cosmetic result was rated higher by patients in the percutaneous group. One patient in the open group had incisional pain and dysesthesia and graded the procedure as ‘fair,’ whereas all others graded their treatment as ‘good.’

Conclusions: These results support the use of percutaneous Achilles tendon repair in the setting of acute ruptures. This conclusion is also supported by other recent literature. Most studies that look at percutaneous vs. open repair advocate the use of percutaneous due to the significantly lower risk of infections (9 vs. 21 percent reported by Lim et al). However, the technique is criticized for its higher rate of re-rupture and sural nerve injury when compared to open repair. Of note, no sural nerve symptoms were reported in this study. This could be explained by the effort to visualize the nerve in the proximal lateral incision prior to needle insertion. In the Panagiotis study, no infections or re-ruptures were reported in either group and the functional outcomes were the same.