SLR - October 2016 - Mary Martin
Reference: Bae SH, Lee HS, Seo SG, Kim SW, Gwak HC, Bae SY. Debridement and Functional Rehabilitation for Achilles Tendon Infection Following Tendon Repair. J Bone Joint Surg Am. 2016 Jul 20;98(14):1161–7.Scientific Literature Review
Reviewed By: Mary Martin, DPM
Residency Program: St. Vincent Hospital – Worcester, MA
Podiatric Relevance: According to recent studies, the incidence of Achilles tendon ruptures has increased in the past 20 years. The incidence of complications from these repairs has increased proportionally. In the face of a deep infection following an Achilles repair, many surgeons will perform tendon transfers to fill the defect after radical debridement of the Achilles. This retrospective review demonstrates a different technique, wherein the damaged portion of the Achilles is resected, the wound is closed and the defect is allowed to fill with scar tissue. Their hypothesis was that they could achieve similar healing and functional outcomes with this technique as compared to other approaches.
Methods: In this retrospective review, 15 patients were determined to have deep postoperative infections following an Achilles rupture repair. The infected tissue was debrided, and the Achilles tendon was radically resected, varying from 4 to 6cm of full-thickness tendon. The tendon sheath was repaired to reduce the amount of dead space. The patient was then allowed to partially bear weight in a short leg splint for two weeks, followed by an ankle brace for four weeks, with full weightbearing allowed after the first two weeks. Vigorous rehabilitation was encouraged following the wound-healing. The patient’s range of motion, calf circumference, single-limb heel rise and overall satisfaction were assessed. Laboratory tests (ESR and CRP) and postoperative ultrasonography were performed. The patients were kept on IV antibiotics for an average of 15 days postoperatively, followed by oral antibiotics for an average of 16 days.
Results: At an average of 17 days postoperatively, the surgical site was healed, and sutures were removed. These patients were followed for an average of 33 months postoperatively, and at the latest follow-up, no patient had signs of an active infection. Eight of the patients had no difference in range of motion compared to the contralateral side. Three of the patients had a dorsiflexion deficit, and five of the patients had a plantarflexion deficit. Calf circumference was decreased compared to the contralateral side in all patients, with an average of 2.4cm decrease. All patients were able to walk on even and uneven terrain without assistance. Nine of the patients rated their outcome as excellent, the other six as good. Ten of the patients were able to perform a single-limb heel rise postoperatively. Three of the five who could not perform the single-heel rise postoperatively could not perform it on the contralateral limb, and related they had not been able to perform it on the operative limb preoperatively. Radiographically, no calcific or osteolytic lesions were observed postoperatively. At a mean of 27 months, the Achilles tendon fibers at the site of radical resection had been replaced with diffuse homogenous fibrous tissue. ESR and CRP levels normalized within four to six weeks postoperatively.
Conclusions: The authors concluded that as long as the infected tissue is fully debrided, successful results can be obtained even without additional tendon transfer. This approach is one of many options available, and that surgical selection has to be done on a case-by-case basis. Based on the relatively low rate of infections after Achilles repairs, there simply may not be enough data to support one technique over the rest.