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A Closer Look At The Benefits Of Minimally Invasive Achilles Tendon Rupture Repair

Challenging the traditional open approach to Achilles tendon ruptures, these authors note that minimally invasive repair of the Achilles facilitates less incidence of re-rupture, fewer wound complications and an earlier return to activity. 

The optimal modality for treating acute Achilles tendon ruptures continues to be a subject of debate in the current foot and ankle literature. Opposing arguments center around conservative versus surgical management as well as the best surgical methods.

Supporters of the non-surgical approach to acute Achilles tendon ruptures point to the comparatively high postoperative infection rates, painful scarring and adhesions around the incision site, which one can encounter with surgery.

Supporters of the surgical management of acute Achilles tendon ruptures highlight the increased postoperative functional outcomes as well as decreased re-rupture rates. The introduction of the mini-open approach to managing acute Achilles tendon ruptures addresses the aforementioned concerns of both sides, namely in decreasing surgical site infection rates through a shorter operating room time, less dissection and smaller incisions while also offering the benefits of surgery such as improved functional outcomes and lower rates of re-rupture.

We believe the mini-open approach for the treatment of acute Achilles tendon ruptures offers patients the best possible outcome.

A Closer Look At The Research On Achilles Repair

While the focus of our discussion here is on the most desirable surgical approach for treating acute Achilles tendon ruptures, other authors have pointed out that clinicians can successfully treat these types of injuries with conservative care. In a randomized, controlled trial, Soroceanu and colleagues assessed 826 patients and found the re-rupture rate to be similar between the non-surgical cohort and the surgical cohort when the non-surgical group had functional rehabilitation.1 However, the surgical group in this study did not have functional rehabilitation. The authors point out that if patients do not have functional rehab after receiving conservative care, surgery has an 8.8 percent greater risk reduction of re-rupture. Soroceanu and coworkers conclude that surgical patients returned to work almost 20 days sooner and had lower rates of re-rupture than the non-operative group when post-operative protocols were similar.

In another level 1 randomized control trial involving patients with acute Achilles tendon ruptures, Willitis and coworkers concluded that patients in a surgically treated group had greater plantarflexory strength at one and two years postoperatively than the non-surgical group.2

Non-surgical treatment for acute Achilles tendon ruptures may be a viable option for patients who are immunocompromised, elderly, low demand, vascularly compromised and/or non-adherent. However, in the majority of people who suffer an acute Achilles tendon rupture, numerous studies have shown better outcomes in patients who elect to undergo surgical repair.

One study comparing surgical treatment and accelerated rehabilitation versus non-surgical care for acute Achilles tendon ruptures showed that patients who had surgical treatment had superior functional results with the drop countermovement jump and hopping.3 The authors also reported no re-ruptures in the surgical repair group versus 10 percent in the conservative management cohort. Another report had similar results, citing better functional outcomes in the surgical group and a re-rupture rate of 4 percent in patients who had surgery in comparison to 12 percent in patients who had conservative care.4

In a systematic review of exclusively level 1 evidence, Wilkins and Bisson found significantly lower re-rupture rates (3.6 percent) in surgically managed patients in comparison to conservatively managed patients (8.8 percent).5 The authors also noted that surgical patients returned to work 7.5 days earlier than non-surgical patients. Similarly, a 2005 meta-analysis showed a re-rupture rate of 12.6 percent for non-operative management, 3.2 percent for the traditional open approach and 2.1 percent for the mini-open approach.6 In a Cochrane Review, the authors examined 844 cases and found the re-rupture rates were 5 percent in the surgical group and 12 percent in the non-surgical group.7

Comparing The Traditional Open And Mini-Open Approaches

The traditional open approach for fixing mid-substance Achilles tendon ruptures typically involves a large 5 to 8 cm incision along the posterior aspect of the ankle with a direct end-to-end repair of the tendon stumps. The surgeon can use the Krackow locking stitch, the most commonly utilized stitch, to reapproximate the tendon ends.

One of the risks of the traditional open approach is surgical site infection. Such complications can be particularly worrisome given the proximity to the Achilles tendon. In a Cochrane Review, the authors found the mini-open approach had fewer post-op wound infections (0 percent) than the traditional open approach (18 percent).7 A 2005 meta-analysis showed a wound complication rate for the traditional open approach of 4.0 percent in comparison with 0 percent for the mini-open approach.5 In their systematic review, Bartel and colleagues found a wound complication rate of 0.8 percent for the mini-open approach.8 Another study comparing results of the mini-open approach to those of the traditional open method found 3 percent of patients treated with the mini-open approach developed superficial wound dehiscence.9 This is in comparison to 8 percent of patients in the open group who developed either a superficial wound dehiscence, a superficial infection or a deep infection.

Further issues with the traditional open approach center around the relatively large incision the surgeon places directly next to the Achilles tendon. Wound edge necrosis, painful hypertrophic scarring and adhesions between soft tissue layers are not entirely uncommon in light of the relatively large incisions surgeons use in the traditional open method of repairing acute Achilles tendon ruptures.

Advocates of the traditional open approach often point to the strength of Krackow locking stitches to reapproximate the ruptured tendon edges. In response to such claims, one study found that the strength of repair in the mini-open approach was equal to that of the traditional open method of addressing acute Achilles ruptures.10 Another investigation examined the strength of the mini-open approach in comparison with the traditional open method.11 The authors found that the former had a higher load to failure in comparison to the traditional open approach utilizing Krackow locking stitches.

Finally, the literature has shown that surgically managed patients with Achilles tendon ruptures have better functional results and return to work sooner than those managed non-operatively. In comparing the mini-open approach directly to the traditional open method, Hsu and coworkers found that more patients who had the mini-open approach were able to return to baseline activity by five months in comparison to those who had the traditional open approach at five months.9

In Conclusion

In comparison to conservatively managed patients and those who received the traditional open method, the mini-open approach for addressing acute mid-substance ruptures of the Achilles tendon has lower re-rupture rates, a lower incidence of wound complications, shorter operating room time, less need for post-op opiates, faster return to activity and earlier return to work. Each of these improvements over the conservative and traditional open approach are not only cost saving for the patient but also have wider societal cost savings.

One study examining the cost-effectiveness of the mini-open approach versus the traditional open method found the latter to cost approximately twice as much as the mini-open procedure (based partially on operating room time and operative complications).12 While one could argue that the systems used for the mini-open approach are more expensive in terms of direct comparison of cost of materials, the potential increased cost is offset many times over for the reasons noted above.

Although there is certainly a learning curve to the mini-open approach, the improved outcomes suggest it is a better alternative moving forward for repairing the majority of acute Achilles tendon ruptures. The current literature continues to support the case of the mini-open approach being a better option for treating acute Achilles tendon ruptures in comparison to both conservative management as well as the traditional open method.

Dr. Hook is in private practice at Midland Orthopedic Associates and is affiliated with the Podiatric Medicine and Surgery Residency Program at Mercy Hospital and Medical Center in Chicago.

Dr. Wirt is a second-year resident at Mercy Hospital and Medical Center in Chicago.

References

1. Soroceanu A, Sidhwa F, Aarabi S, et al. Surgical versus nonsurgical treatment of acute achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012; 94(23):2136-43.

2. Willitis K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehab. J Bone Joint Surg. 2010; 92(17):2767-75.

3. Olsson N, Silbernagel KG, Eriksson BI, et al. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013;41(12):2867-76.

4. Nilsson-Helander K, Silbernagle KG, Thomee R, et al. Acute Achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010; 38(11):2186–93.

5. Wilkins R, Bisson L. Management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. Am J Sports Med. 2012; 40(9):2154–60.

6. Khan RJ, Fick D, Keogh A, et al. Treatment of acute Achilles tendon ruptures. J Bone Joint Surg Am. 2005; 87(10):2202-2210.

7. Khan RJK, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010; 9:CD003674.

8. Bartel AF, Elliott AD, Roukis TS. Incidence of complications after Achillon mini-open suture system for repair of acute midsubstance Achilles tendon ruptures: a systematic review. J Foot Ankle Surg. 2014; 53(6):744-746.

9. Hsu AR, Jones CP, Cohen BE, et al. Clinical outcomes and complications of percutaneous Achilles repair system versus open technique for acute Achilles tendon ruptures. Foot Ankle Int. 2015; 36(11):1279-86.

10. Clanton TO, Haytmanek CT, Williams BT, et al. A biomechanical comparison of an open repair and 3 minimally invasive percutaneous Achilles tendon repair techniques during a simulated, progressive rehabilitation protocol. Am J Sports Med. 2015; 43(8):1957-64.

11. 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.

12. Carmont MR, Heaver C, Pradhan A, Mei-Dan O, Gravare Silbernagel K. Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair. Knee Surgery Sports Traumatol Arthrosc. 2013; 21(6):1361-1368.

Additional References

13. McGlamry E. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery, Fourth Edition. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, 2013.

14. Hsu AR, Jones CP, Cohen BE, et al. Clinical outcomes and complications of percutaneous Achilles repair system versus open technique for acute Achilles tendon ruptures. Foot Ankle Int. 2015; 36(11):1279–86.

15. Carmont MR, Heaver C, Pradhan A, Mei-Dan O, Gravare Silbernagel K. Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair. Knee Surgery Sports Traumatol Arthrosc. 2013; 21(6):1361–8.

16. Teiwani NC, Lee J, Weatherall J, Sherman O. Acute Achilles tendon ruptures: a comparison of minimally invasive and open approach repairs followed by early rehabilitation. American J Orthoped. 2014; 43(10):E221-5.

17. Karbinas PK, Benetos IS, Lampropoulou-Adamidou K, et al. Percutaneous versus open repair of acute Achilles tendon ruptures. Eur J Orthoped Surg Traumatol. 2014; 24(4):607-13.

18. Porter KJ, Robati S, Karia P, et al. An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device. Foot Ankle Surg. 2014; 20(2):90-93.

19. Hutchison AM, Topliss C, Beard D, Evans RM, Williams P. The treatment of a rupture of the Achilles tendon using a dedicated management programme. Bone Joint J. 2015; 97-B(4):510-15.

20. Olsson N, Silbernagle KG, Eriksson BI, et al. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2014; 41(2):2867–76.

21. Giannetti S, Patricola AA, Stancati A, Santucci A. Intraoperative ultrasound assistance for percutaneous repair of the acute Achilles tendon rupture. Orthopedics. 2014; 37(12):820-824.

Online Exclusives
Jonathan L. Hook, DPM, MPH, and T. Craig Wirt, DPM, PhD
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