J Korean Foot Ankle Soc.  2018 Jun;22(2):68-73. 10.14193/jkfas.2018.22.2.68.

Comparative Study of Clinical Outcome of Three Surgical Techniques in the Achilles Tendon Rupture: Open Repair, Percutaneous Repair, and Minimal Incision Repair by Achillon

• Park WS
• Lee MJ
• Kang JM
• Lee SY

• KMID: 2413715
• DOI: http://doi.org/10.14193/jkfas.2018.22.2.68

Abstract

PURPOSE
This study compared the clinical outcomes of open repair, percutaneous repair, and minimal incision repair by Achillon in ruptured Achilles tendon.
MATERIALS AND METHODS
The outcomes of 12 patients with open repair (group 1), 8 patients with percutaneous repair (group 2), and 10 patients with minimal incision repair by Achillon (group 3) from February 2013 to March 2016 were analyzed retrospectively. The postoperative clinical evaluations were done by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Arner-Linholm scale, mid-calf circumference difference, one-leg heel raise difference, visual analogue scale (VAS) for postoperative scarring, time to return to work, and complications.
RESULTS
No significant difference in the AOFAS ankle-hindfoot score, Arner-Linholm scale, and time to return to work was observed among three groups (p=0.968, 0.509, and 0.585). The mean differences in the mid-calf circumference in groups 1, 2, and 3 were 1.09, 0.73, and 0.58, respectively; groups 2 and 3 were significantly higher than group 1 (p=0.002). In addition, the mean VAS scores for postoperative scarring in groups 1, 2, and 3 were 7.0, 9.1, and 9.1, respectively; groups 2 and 3 were significantly higher than group 1 (p=0.001). The mean differences in one-leg heel raising in groups 1, 2, and 3 were 2.03, 1.91, and 1.33, respectively; group 3 was significantly higher than groups 1 and 2 (p=0.010). The complications encountered were one case of deep infection in group 1 and one case of sural nerve hypoesthesia in group 2.
CONCLUSION
Minimal incision repair by Achillon is recommended as an effective surgical treatment for Achilles tendon rupture because it minimizes the risk of complications, leads to an improved tendon strength and healing, and achieves cosmetic satisfaction.

Keyword

Achilles tendon; Rupture; Open repair; Percutaneous repair; Achillon

MeSH Terms

Achilles Tendon*
Ankle
Cicatrix
Foot
Heel
Humans
Hypesthesia
Retrospective Studies
Return to Work
Rupture*
Sural Nerve
Tendons

Figure

• 

  Figure 1 Intraoperative photograph that open repair (A) using 2-0 Ethibond by Krackow's suture technique (B).

• 

  Figure 2 (A) Preoperative marking of incision was made over the area of the rupture confirmed by ultrasonography in percutaneous repair. (B) Suture configuration of Carmont & Maffulli procedure.

• 

  Figure 3 (A) Minimal incision Achilles tendon repair by the Achillon was introduced proximal Achilles tendon stump. (B) The same procedure was performed on the distal stump. (C) Ruptured Achilles tendon was repaired by indirect suture technique by 3 separate sutures.

Reference

1. Raikin SM, Garras DN, Krapchev PV. Achilles tendon injuries in a United States population. Foot Ankle Int. 2013; 34:475–480.

2. Jung HG, Paik HD. Surgical repair of Achilles tendon rupture by minimal incision technique. J Korean Foot Ankle Soc. 2005; 9:173–178.

3. Deangelis JP, Wilson KM, Cox CL, Diamond AB, Thomson AB. Achilles tendon rupture in athletes. J Surg Orthop Adv. 2009; 18:115–121.

4. Azar FM. Rupture of muscles and tendons. Achilles tendon injuries. In : Campbell WC, Canale ST, Beaty JH, editors. Campbell's operative orthopaedics, Vol 3. 11th ed. Philadelphia: Mosby/Elsevier;2008. p. 2748–2753.

5. Cretnik A, Kosanović M, Smrkolj V. Percutaneous suturing of the ruptured Achilles tendon under local anesthesia. J Foot Ankle Surg. 2004; 43:72–81.

6. Jeon TS, Kim SB, Jung WY, Heo YM, Park CY. Percutaneous repair of acute Achilles tendon ruptures. J Korean Orthop Assoc. 2009; 44:661–667.

7. 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; 21:791–799.

8. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. 1999; 81:1019–1036.

9. Mukundan C, El Husseiny M, Rayan F, Salim J, Budgen A. “Miniopen” repair of acute tendo Achilles ruptures--the solution? Foot Ankle Surg. 2010; 16:122–125.

10. Fortis AP, Dimas A, Lamprakis AA. Repair of Achilles tendon rupture under endoscopic control. Arthroscopy. 2008; 24:683–688.

11. Tang KL, Thermann H, Dai G, Chen GX, Guo L, Yang L. Arthroscopically assisted percutaneous repair of fresh closed Achilles tendon rupture by Kessler's suture. Am J Sports Med. 2007; 35:589–596.

12. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005; 87:2202–2210.

13. Ahmed IM, Lagopoulos M, McConnell P, Soames RW, Sefton GK. Blood supply of the Achilles tendon. J Orthop Res. 1998; 16:591–596.

14. Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study. Am J Sports Med. 1990; 18:188–195.

15. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon--a prospective randomized controlled study. Foot Ankle Int. 2001; 22:559–568.

16. Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res. 1977; (128):247–255.

17. Sutherland A, Maffulli N. A modified technique of percutaneous repair of ruptured Achilles tendon. Orthop Traumatol. 1999; 7:288–295.

18. Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P. 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; 84:161–170.

19. 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; 40:188–194.

20. Rippstein PF, Jung M, Assal M. Surgical repair of acute Achilles tendon rupture using a “mini-open” technique. Foot Ankle Clin. 2002; 7:611–619.

21. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994; 15:349–353.

22. Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl. 1959; 116:Suppl 239. 1–51.

23. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012; 94:2136–2143.

24. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, 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; 92:2767–2775.

25. Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, et al. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010; 18:503–510.

26. Saxena A, Maffulli N, Nguyen A, Li A. Wound complications from surgeries pertaining to the Achilles tendon: an analysis of 219 surgeries. J Am Podiatr Med Assoc. 2008; 98:95–101.

27. Kosanović M, Cretnik A, Batista M. Subcutaneous suturing of the ruptured Achilles tendon under local anaesthesia. Arch Orthop Trauma Surg. 1994; 113:177–179.

28. Huffard B, O'Loughlin PF, Wright T, Deland J, Kennedy JG. Achilles tendon repair: Achillon system vs. Krackow suture: an anatomic in vitro biomechanical study. Clin Biomech (Bristol, Avon). 2008; 23:1158–1164.