Point-Counterpoint: Acute Achilles Tendon Repair: Is The Mini-Open Approach Better Than An Open Approach?

Cook.png [3]

Sung.png [4]

Yes.

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.

[5]

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

   When comparing the open approach, the combined mini-open and percutaneous technique and the percutaneous technique, Rebeccato and co-workers found the strength of the repaired extremity was 75 percent in the open repair group, 88 percent in the percutaneous repair group and 92 percent in the combined mini-open and percutaneous procedure group in comparison to the uninvolved extremity.¹⁰

   Furthermore, researchers obtained postoperative MRIs on these patients and they found the total area thickness of the posterior calf of the repaired leg was 82 percent in comparison to the uninjured leg in the open repair, 81 percent in the percutaneous procedure and 91 percent in the combined mini-open and percutaneous procedure. The authors concluded that the combined mini-open and percutaneous repair provided significantly better results than the other two procedures.¹⁰

   Aktas and Kocaoglu reported the only prospective, randomized control trial comparing the traditional open repair and mini-open techniques.²¹ They enrolled a total of 40 consecutive patients, who were randomized into the traditional open or the mini-open groups. The open repair consisted of the Krackow end-to-end suture repair while the mini-open technique was similar to that reported by Assal and colleagues.¹⁶ The authors used the American Orthopedic Foot and Ankle Society’s (AOFAS) hindfoot clinical outcome score postoperatively and found the traditional open group scored 98.7/100 and the mini-open group scored 96.8/100.

   Despite similar clinical outcomes, the mini-open group did have fewer complications including decreased local tenderness, fewer adhesions and thinner scar appearances.²¹ The authors concluded that the mini-open repair was safe, reliable and practical for repairing acute Achilles tendon ruptures with a low risk of complications.

   A recent meta-analysis compared six randomized controlled trials for Achilles tendon repair.¹⁹ In the review, there were 277 Achilles repairs included with 136 mini-open repairs and 141 traditional open repairs. The analysis yielded no statistical differences between the groups for incidence of re-rupture, tissue adhesion, sural nerve injury, deep infection or deep vein thrombosis.

   However, researchers noted the mini-open group had a significantly decreased rate of infection with a threefold higher incidence of subjective good to excellent results.

Final Notes

Researchers have shown that the mini-open technique for Achilles tendon repair reduces the morbidity associated with a traditional open repair for surgical management of acute ruptures.

   Moreover, the advances in the mini-open instrumentation have allowed surgeons to use a less invasive exposure while increasing the likelihood of reproducibility of the procedure. It is likely that the trend of positive outcomes will continue to differentiate the mini-open repair as the optimal choice for operative acute Achilles tendon repair.

   Dr. Sung is a fellowship-trained foot and ankle surgeon. He is an attending physician with the Sinai Medical Group in Chicago and is the Residency Education Coordinator with the Mount Sinai Hospital Podiatric Residency Program in Chicago.

References
1. Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67(3):277-9.
2. Chiodo CP, Wilson MG. Current concepts review: acute ruptures of the achilles tendon. Foot Ankle Int. 2006;27(4):305-13.
3. Mukundan C, El Husseiny M, Rayan F, et al. “Mini-open” repair of acute tendo Achilles ruptures — the solution? Foot Ankle Surg. 2010;16(3):122-5.
4. McMahon SE, Smith TO and Hing CB. A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot Ankle Surg. 2011;17(4):211-7.
5. Carter TR, Fowler PJ, Blokker C. Functional postoperative treatment of Achilles tendon repair. Am J Sports Med. 1992;20(4):459-62.
6. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21(6):791-9.
7. Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med. 2003;31(5):692-700.
8. Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. J Bone Joint Surg Am. 1999;81(7):983-90.
9. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-75.
10. Rebeccato A, Santini S, Salmaso G, Nogarin L. Repair of the Achilles tendon rupture: a functional comparison of three surgical techniques. J Foot Ankle Surg. 2001;40(4):188-94.
11. Hockenbury RT and Johns JC. A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles. Foot Ankle. 1990; 11(2):67-72.
12. Fujikawa A, Kyoto Y, Kawaguchi M, et al. Achilles tendon after percutaneous surgical repair: serial MRI observation of uncomplicated healing. AJR Am J Roentgenol. 2007;189(5):1169-74.
13. Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achilles. Comparison with open repair. J Bone Joint Surg Br. 1995;77(1):60-3.
14. Lui TH. Surgical tip: repair of acute Achilles rupture with Krackow suture through a 1.5 cm medial wound. Foot Ankle Surg. 2010;16(1):28-31.
15. Ng ES, Ng YO, Gupta R, et al. Repair of acute Achilles tendon rupture using a double-ended needle. J Orthop Surg (Hong Kong). 2006;14(2):142-6.
16. Assal M, Jung M, Stern R, et al. Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am. 2002. 84-A(2):161-70.
17. Calder JD, Saxby TS. Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med. 2005;39(11):857-9.
18. Ismail M, Karim A, Shulman R, et al. The Achillon Achilles tendon repair: is it strong enough? Foot Ankle Int. 2008;29(8):808-13.
19. Heitman DE, Ng K, Crivello KM, Gallina J. Biomechanical comparison of the Achillon tendon repair system and the Krackow locking loop technique. Foot Ankle Int. 2011;32(9):879-87.
20. Bhattacharyya M, Gerber B. Mini-invasive surgical repair of the Achilles tendon--does it reduce post-operative morbidity? Int Orthop. 2009;33(1):151-6.
21. Aktas S, Kocaoglu B. Open versus minimal invasive repair with Achillon device. Foot Ankle Int. 2009;30(5):391-7.

Additional References
22. Inglis AE, Scott WN, Sculco TP, Patterson AH. Ruptures of the tendo Achilles. An objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am. 1976;58(7):990-3.
23. Lea RB, Smith L. Non-surgical treatment of tendo achillis rupture. J Bone Joint Surg Am. 1972;54(7):1398-407.
24. Nistor L. Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study. J Bone Joint Surg Am. 1981;63(3):394-9.
25. Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture. A review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1986;(207):156-63.
26. De Carli A, Vadala A, Ciardini R, et al. Spontaneous Achilles tendon ruptures treated with a mini-open technique: clinical and functional evaluation. J Sports Med Phys Fitness. 2009;49(3):292-6.
27. Rippstein PF, Jung M, Assal M. Surgical repair of acute Achilles tendon rupture using a “mini-open” technique. Foot Ankle Clin. 2002;7(3):611-9.
28. Robinson JM, Cook JL, Purdam C, et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. 2001;35(5):335-41.

   For further reading, see “A Closer Look At Mini-Incision Repair Of The Acute Achilles Tendon Rupture” in the November 2011 issue of Podiatry Today or the DPM Blog “A Closer Look At Surgical Options For Neglected Tendon Ruptures” at http://goo.gl/mBiK1 [6] .

No.

This author says percutaneous repair has well documented complications and open repair allows for more certainty and reinforcement of tendon repair.

[7]

By Keith D. Cook, DPM, FACFAS

After completing a thorough history and physical examination of the injured patient, and analyzing all appropriate studies that may include X-rays, MRI and ultrasound, the foot and ankle surgeon must first determine if the patient diagnosed with an acute rupture of the Achilles tendon is a surgical candidate. Recent literature has shown that conservative treatment of Achilles tendon ruptures may have similar outcomes to those patients treated with surgical intervention.^1-4

   Physicians do need to weigh the risks and benefits of surgical intervention versus conservative treatment. Non-surgical treatment may be in the best interest of patients with multiple comorbidities, smokers, and obese patients who could be at a higher risk for perioperative complications. The patient and surgeon need to make a joint decision to proceed with surgical repair.

   When discussing percutaneous versus open techniques for repair of Achilles tendon ruptures, it is imperative that the foot and ankle surgeon understand the difference. The nomenclature can often be misleading. Open repair of the Achilles tendon involves visualizing the tendon ends through an incision to confirm their apposition. Minimally invasive techniques fall into this category of open repair albeit through a smaller incision.
In contrast, true percutaneous repair of the Achilles tendon does not allow for direct visualization of the tendon ends.⁵ Ma and Griffith first described this technique of passing the suture through small stab incisions in 1977.⁶

   The complications associated with percutaneous repair have been well documented. Majewski and co-authors reported that sural nerve injury, the most common complication, occurred in up to 18 percent of patients.⁷ Comparative studies have also shown an increased rate of re-rupture in patients treated with percutaneous techniques as opposed to open repairs.^5,8

Questioning The ‘Uncertainty’ Of Percutaneous Repair

However, the greatest disadvantage of percutaneous repair of Achilles tendon ruptures is the uncertainty of knowing whether the tendon ends are well apposed after tying the sutures. Also, the surgeon cannot ascertain the condition of the tendon or correct any rotational or intra-substance tendon deformity associated with the injury. This is a purely blind approach. Hoping for “the best” may not maximize the patient’s outcome.

   The recent advent of Achilles tendon guides or jigs to assist with the placement of the sutures through the ruptured Achilles tendon have made minimally invasive techniques more popular. However, as I discussed above, these techniques can still be considered open repairs. The jigs have helped to decrease the rate of sural nerve injury while allowing confirmation by the surgeon that the tendon ends are well apposed upon suture tying.^5,9,10

   I still prefer a traditional open technique when repairing Achilles tendon ruptures. I make a linear incision from proximal to distal over the Achilles defect with medial placement to the midline of the tendon. Doing so avoids the sural nerve and decreases the risk of nerve injury.

   Meticulous dissection, gentle handling of the soft tissue envelope and preservation of the paratenon when possible are important for optimizing outcomes. Utilizing an open technique allows for proper evacuation of any hematoma within the tendon defect, reassuring that the ends of the ruptured tendon will be re-approximated. Foot and ankle surgeons can also pass the non-absorbable suture of their choice through the substance of the tendon via any number of suture techniques.

   As the exact location of the tendon rupture varies from patient to patient, the segment of tendon distal to the rupture may be quite short at its insertion into the calcaneus. Therefore, it is not always possible to pass percutaneous sutures through the distal tendon with certainty of a strong repair. A box or Krackow suture technique may be required in this instance.

   The biggest advantage of utilizing an open technique in Achilles tendon repairs is the certainty that the tendon ends are appropriately re-approximated upon tying the sutures. One can also reinforce the tendon with additional, usually absorbable, sutures as needed.

   Another advantage to the open technique is having the ability to augment your repair when needed with the use of the adjacent plantaris tendon. If this tendon is not present, the surgeon may use another tendon of his or her choice. This at times is invaluable in creating a strong repair with a smooth gliding surface, which is not possible through the percutaneous approach.

Other Advantages Of The Open Repair

As with any surgery, there are always the unexpected situations that arise intra-operatively. The foot and ankle surgeon must be aware of this when performing Achilles tendon repairs. One obstacle is the retracted tendon ends and the inability to appose the tendon. These situations often necessitate the use of a gastrocnemius recession or a turn down technique of the proximal tendon end in order to lengthen the tendon, and properly repair the ruptured Achilles. These techniques are not possible with percutaneous repair of an Achilles tendon rupture.

   As a residency educator, I feel the open technique for Achilles tendon repairs also plays a role in properly training future foot and ankle surgeons. Residents need to understand how the anatomy is affected with an Achilles tendon rupture as well as the biomechanical principles involved in the repair. There is much more to performing this surgery than just suturing two ends of a tendon together. A surgeon should be able to reconstruct the Achilles tendon to its normal anatomy to the best of her or his ability.

   One needs to ensure the application of proper biomechanical forces or tension across the repair site as well. An Achilles tendon that is too tight can result in an equinus deformity and one which is too loose may result in biomechanical weakness or a calcaneal gait. Adequate visualization of the repair will accomplish this. These are important concepts for the trainee to learn.

   Surgical procedures come with risks and complications, and Achilles tendon repairs are no different. In some instances, there are even greater risks involved due to the nature of the injury and the poor vascularity at the rupture site. I attempt to decrease the incidence of wound dehiscence via layered closure utilizing a minimal amount of subcutaneous sutures.

   The idea is to decrease the potential of subcutaneous suture reaction. I close the skin with an absorbable monofilament suture in a running fashion. Accordingly, one does not need to remove the suture and continuous equal tension occurs across the incision until it is completely healed.

   Researchers have also shown that instituting early postoperative weightbearing protocols and physical therapy programs decrease complication rates.¹¹ A confident anatomic repair can allow the initiation of physical therapy sooner rather than later. Studies have shown how early ambulation and physical therapy result in better functional outcomes than prolonged immobilization. Early weightbearing is also beneficial for psychosocial reasons and improves health-related quality of life without long-term side effects.^2,3,11,12

Final Notes

Foot and ankle surgeons should choose their patients carefully when considering the repair of an Achilles tendon rupture. If a patient is a suitable surgical candidate, I advocate the open repair approach for the many aforementioned benefits. Blindly suturing a tendon and hoping to have a good anatomic repair is inferior to the confidence in knowing that you have performed a strong Achilles tendon repair. One can subsequently initiate early weightbearing and physical therapy to decrease the risk of complications associated with these injuries and improve outcomes.

   Dr. Cook is the Director of Podiatric Medical Education and an Assistant Director of the Podiatry Service at the University Hospital with the University of Medicine and Dentistry of New Jersey in Newark, N.J. He is a Fellow of the American College of Foot and Ankle Surgeons.

References
1.  Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: Is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35(12):2033-2038.
2. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg. 2010;92(17):2767-2775.
3. Metz R, Verleisdonk EJ, van der Heijden GJ, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing-a randomized controlled trial. Am J Sports Med. 2008;36(9):1688-1694.
4. Wallace RG, Heyes GJ, Michael AL. The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture. J Bone Joint Surg. 2011;93(10):1362-1366.
5.  Carmont MR, Rossi R, Scheffler S, et al. Percutaneous and mini invasive Achilles tendon repair. Sports Med Arthrosc Rehabil Ther Technol. 2011:3:28-36.
6. Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res. 1977;128:247-255.
7. Majewski M, Rohrbach M, Czaja S, et al. Avoiding sural nerve injuries during percutaneous Achilles tendon repair. Am J Sports Med. 2006:34(5):793-798.
8.  Cretnik A, Kosanovic M, Smrkoli V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med. 2005;33(9):1369-1379.
9.  Calder JD, Saxby TS. Independent evaluation of a recently described Achilles tendon repair technique. Foot Ankle Int. 2006:27(2):93-96.
10.  Ismail M, Karim A, Shulman R, et al. The Achillon Achilles tendon repair: is it strong enough? Foot Ankle Int. 2008:29(8):808-813.
11.  Talbot JC, Williams GT, Bismil Q, et al. Results of accelerated postoperative rehabilitation using novel “suture frame” repair of Achilles tendon rupture. J Foot Ankle Surg. 2012;51(2):147-151.
12.  Suchak AA, Bostick GP, Beaupre LA, et al. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am. 2008:90(9):1876-1883.

   For further reading, see “Current Concepts In Treating Achilles Tendon Ruptures” in the September 2009 issue of Podiatry Today, “How To Address The Neglected Achilles Tendon Rupture” in the November 2011 issue or the DPM Blog “A Closer Look At The Three-Knot Layered Krackow Achilles Repair” at http://goo.gl/xoG4C [8] .