Point-Counterpoint: Acute Achilles Tendon Repair: Is The Mini-Open Approach Better Than An Open Approach?
This author says the majority of the current research shows that incorporation of the mini-open repair may provide a more viable option than traditional open repair with reduced complications.
By Wenjay Sung, DPM
While acute Achilles tendon ruptures are common lower extremity injuries, the ideal intervention continues to be up for debate.1,2 Non-operative care, operative mini-open repair and traditional open repair of the acute Achilles tendon ruptures all have their benefits and risks.2 Recent studies have advocated the use of the mini-open technique as a safe and effective means of repairing a ruptured Achilles tendon with fewer complications than open repair.3,4
The traditional open Achilles tendon repair allows direct visualization of apposing ruptured tendon ends. However, researchers have reported postoperative complications such as wound edge necrosis, dehiscence, hypertrophic scarring, adhesions, infections and sural nerve injuries.5-9 The traditional open repair technique generally involves a long incision into a region of skin with possible vascular compromise and extensive stripping of the paratenon.5,6,10
Percutaneous approaches developed to avoid extensive surgical dissection, thereby minimizing disturbance to local blood supply. However, the ability to debride a presenting hematoma was decreased with percutaneous repair and the ability to realign the tendon ends was not as reliable.11,12 One cadaver study demonstrated this limitation by underscoring possibly misaligned Achilles tendon ends via the percutaneous technique.11
What The Literature Reveals About The Mini-Open Approach
After a period of trials and innovation, various authors introduced the mini-open Achilles tendon repair as a natural evolution to the percutaneous technique.13-15 In a cadaver study, Assal and colleagues developed a specialized device to assist with the mini-open surgical technique.16 The reported advantages of this technique include the ability to visualize the ruptured Achilles tendon ends, the ability to keep all sutures entirely in the paratenon, and reduced potential for incision dehiscence and tendon adhesions.
Other authors further modified the mini-open technique with a horizontal incision 1 cm distal to the proximal tendon stump, attempting to improve wound healing and cosmetic appearance.17
However, some authors were concerned with the strength of tendon repair after comparing the mini-open technique to the traditional open repair technique. One study found that the mean load to failure was not significantly different between the mini-open and the Kessler methods of repair.18 Another investigation found that the mini-open repair technique had a higher load to failure than the traditional Krackow locking stitch.19
Clinical studies further advanced the mini-open repair as a valid alternative to the traditional open repair. One study compared the treatment of acute Achilles tendon ruptures with the mini-open technique to an open repair technique.13 There were 12 patients treated with mini-open repair versus 10 patients treated with traditional open repair. Although researchers used no validated clinical assessment score, physician examination and patient interviews demonstrated statistically significant better outcomes in the mini-open repair group.
Another study compared the postoperative morbidity of patients treated with the mini-open technique versus patients treated with the traditional open technique.20 All patients in both groups were allowed full weightbearing eight weeks after operative intervention. The results showed the open repair group had an increase in postoperative wound infections and had a longer period of wound healing in comparison to the mini-open group. The authors concluded that the mini-open technique and instrumentation might even be cost-effective due to the lack of wound complications and decreased opiate usage in comparison to the traditional open repair technique.20