SLR - September 2011 - Seth M. Felice
Reference: Henriquez, H., MD, Munoz, R. MD, Carcuro, G. MD, Bastias, C. MD (2011). Is Percutaneous Repair Better Than Open Repair in Acute Achilles Tendon Rupture? Clinical Orthopaedics and Related Research, Mar 2 [ePub ahead of print]
Scientific Literature Review
Reviewed by: Seth M. Felice, DPM
Residency Program: St. John Hospital & Medical Center
Podiatric Relevance:
Achilles tendon ruptures occur most frequently in during athletic activities by men during in their third or fourth decade of life, and the optimal treatment of these injuries remains controvertial. While the published literature largely suggests the superiority of operative compared with conservative treatment of this pathology, a more clear consensus regarding the best surgical approach may improve patients' functional outcomes and quality of life after the injury. Just as the arenas of general, vascular, orthopedic, and many other surgical specialties continue to evolve to less invasive repairs, the state of the art in podiatric surgery is no exception. A recent peer reviewed comparison study between percutaneous repair and traditional open repair for the treatment of acute Achilles tendon ruptures is provided.
Methods:
A retrospective review was performed of 93 patients with acute Achilles tendon rupture injuries. 38 patients were immediately excluded due to open rupture, steroid use, re-rupture injuries, previous elective Achilles surgery, or greater than 14 days duration before operative treatment. In 55 patients with acute closed Achilles tendon ruptures, 23 (42%) were lost to follow up. Of the 32 patients available for follow-up, 17 percutaneous and 15 open repairs were compared. IRB approval was obtained, and patients were properly consented.
Open repairs had been routinely performed by this Chilean orthopedics author team until 2006 using a standardized extensile incision medial to the Achilles midline and number 2 FiberWire (Arthrex, Naples, FL). Beginning in 2007, this same team adopted a percutaneous repair according to the technique of Amlang et al (2005, Unfallchirurg) using a small incision and two strands of the same suture, number 2 FiberWire. The two treatment groups were evaluated for outcome results.
All patients were treated with surgery within 14 days of Achilles rupture followed by discharge home the day after surgery in a cast, NWB casting for 6 weeks, standardized physiotherapy, weightbearing with heel lift and return to work at 9 weeks, and full weightbearing and return to sports permitted at 12 weeks post-op. Patients were followed for 6 to 48 months, and function (ROM, muscle strength, return to work), cosmesis (scar length, patient satisfaction), and complication rates (re-tupture, wound problems, or other) were evaluated.
Results:
Similar functional results were obtained in the percutaneous and open Achilles repair groups. Open repairs trended towards greater mean muscle strength (147 N versus 120 N). However, the mean return to work time was significantly lower for the percutaneous repair group (2.8 months) versus the open repairs (5.6 months).
Cosmetic results were largely in favor of the percutaneous repair group. The average scar length favored percutaneous repair technique (2.9cm percutaneous, versus 9.5cm in open repair patients). Patients were more likely to rate the minimally invasive repair than the open repair as cosmetically excellent (53% versus 20%) or excellent/good scar result (100% versus 73%).
Post-operative complications were more frequent in the open repair group. These included two (13%) wound complications and one re-rupture(7%), which was treated with revision including FHL transfer, in the open group. The percutaneously repaired group had no wound issues or re-ruptures, but a DVT in the calf was detected and resolved uneventfully with anticoagulant treatment.
Conclusions:
Surgical treatment is generally preferred over non-operative care for closed acute Achilles tendon ruptures. Open Achilles repairs remain the standard of care due to visualization and proven results, but wound problems, devascularization of the tendon, and prolonged healing are concerns which have led to evolutionary thinking among some foot and ankle surgeons. Percutaneous repair techniques have received significant attention recently, but feared downfalls included higher re-rupture rates or potential for sural nerve damage with a "blind" operative approach.
In the study summarized, a percutaneous repair of Achilles tendon ruptures demonstrated a similar strength and ROM result as open repairs, but significantly faster return to work, better cosmesis, and lower complication rate were obtained with percutaneous repairs than the standard open repair. As all surgical specialties continue to trend towards minimally invasive treatments for surgical pathology, this peer reviewed comparison study, while in a limited sample size and offering only low quality statistical analysis, may help to guide surgeon decision making for this devastating foot and ankle injury. Future research and continued surgical evolution will aid in the optimization of patient outcomes after Achilles tendon ruptures.