A modified, minimally invasive technique for acute Achilles tendon repair using two transverse incisions
Main Article Content
Abstract
Background: Typical complications of the surgical treatment of acute Achilles tendon rupture are wound infection, seroma, skin tethering, sural nerve damage and hypertrophic scar. Some percutaneous or mini-open methods for acute Achilles tendon repair have been developed recently. Many of them have specific complications such as sural nerve damage, scar adhesion at the rupture site or maladaptation of the tendon.
Method: To minimize these complications, we describe a technique using 2 transverse incisions, leaving the rupture site under a bridge of intact peritendineum. The sural nerve is exposed and spared from damage using the cranial incision. The aim of this surgical technique is to minimize complications concerning wound healing, scar adhesions at the rupture site, maladaptation of the tendon ends, damage to the sural nerve and seroma due to large-diameter resorbable sutures.
Results: Between 2008 and 2010, we treated 47 patients with a mean age of 50 years who sustained a complete rupture of the Achilles tendon. Forty-one patients were re-evaluated after an average of 7 months. Thirty-seven Achilles tendons healed without complications. Complications were one delayed wound healing, two re-ruptures after trauma and one deep vein thrombosis.
Conclusion: Combined with a good clinical outcome, this minimally invasive technique may reduce the incidence of sural nerve entrapment. An early functional rehabilitation program is possible with full weight-bearing using a brace.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
Amlang, M. H., Christiani, P., Heinz, P., & Zwipp, H. (2006). The percutaneous suture of the Achilles tendon with the Dresden instrument. Operative Orthopädie und Traumatologie, 18, 287-299. doi:10.1007/s00064-006-1178-y.
Amlang, M. H., & Zwipp, H. (2006). Verletzung großer Sehnen Achilles-, Patellar- und Quadrizepssehne [Damage to large tendons: Achilles, patellar and quadriceps tendons]. Chirurg, 77, 637–649. doi:10.1007/s00104-006-1205-4.
Assal, M., Jung, M., Stern, R., Rippstein, P., Delmi, M., & Hoffmeyer, P. (2002). Limited open repair of Achilles tendon ruptures: A technique with a new instrument and findings of a prospective multicenter study. Journal of Bone and Joint Surgery Am., 84–A, 161–170.
Booth, F. W. (1987). Physiologic and biochemical effects of immobilization on muscle. Clinical Orthopaedics and Related Research, 219, 15–20. doi:10.1097/00003086-198706000-00004.
Carden, D. G., Noble, J., Chalmers, J., Lunn, P., & Ellis, J. (1987). Rupture of the calcaneal tendon. The early and late management. Journal of Bone and Joint Surgery. …, British Volume, 69, 416-420.
Cetti, R., Christensen, S.-E., Ejsted, R., Jensen, N. M., & Jorgensen, U. (1993). Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. American Journal of Sports Medicine, 21, 791-799. doi:10.1177/036354659302100606.
Costa, M. L., Logan, K., Heylings, D., Donell, S. T., & Tucker, K. (2006). The effect of achilles tendon lengthening on ankle dorsiflexion: A cadaver study. Foot and Ankle International, 27, 414-417.
Haertsch, P. A. (1981). The blood supply to the skin of the leg: A post-mortem investigation. British Journal of Plastic Surgery, 34, 470-477. doi:10.1016/0007-1226(81)90061-8.
Haji, A., Sahai, A., Symes, A., & Vyas, J. K. (2004). Percutaneous versus open tendo achillis repair. Foot and Ankle International, 25, 215-218.
Hockenbury, R. T., & Johns, J. C. (1990). A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles. Foot & Ankle, 11, 67-71. doi:10.1177/107110079001100202.
Kannus, P., & Józsa, L. (1991). Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. Journal of Bone and Joint Surgery Am., 73, 1507-1525.
Ker, R. F. (1981). Dynamic tensile properties of the plantaris tendon of sheep (Ovis aries). Journal of Experimental Biology, 93, 283-302.
Klein, W., Lang, D. M., & Saleh, M. (1991). The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo achillis. Chir Organi Mov, 76, 223–228.
Lagergren, C., & Lindholm, A. (1959). Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chirurgica Scandinavica, 116, 491-495.
Lea, R. B., & Smith, L. (1968). Rupture of the Achilles tendon nonsurgical treatment. Clinical Orthopaedics and Related Research, 60, 115-118. doi:10.1097/00003086-196809000-00014.
Leppilahti, J., Puranen, J., & Orava, S. (1996). Incidence of Achilles tendon rupture. Acta Orthopaedica Scandinavica, 67, 277-279. doi:10.3109/17453679608994688.
Ma, G. W., & Griffith, T. G. (1977). Percutaneous repair of acute closed ruptured Achilles tendon: A new technique. Clinical Orthopaedics and Related Research, 128, 247–255. doi:10.1097/00003086-197710000-00036.
Maffulli, N. (1999). Current concepts review. Rupture of the Achilles tendon. Journal of Bone and Joint Surgery, 81-A, 1019-1036.
Maquirriain, J. (2011). Achilles tendon rupture: Avoiding tendon lengthening during surgical repair and rehabilitation. Yale Journal of Biology and Medicine, 84, 289-300.
Mayer, L. (1916). The physiological method of of tendon transplantation. Surgery, Gynecology, and Obstetrics, 22, 182-197.
Mortensen, H. M., Skov, O., & Jensen, P. E. (1999). Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. Journal of Bone and Joint Surgery. … Am., 81, 983-990.
Myerson, M. (1999). Achilles tendon ruptures. Instructional Course Lectures, 48, 219-230.
Paar, O., Klever, P., & Erli, H.-J. (2001). Gefäßversorgung der Achillessehne - Radiologische, mikroradiographische und histologische Untersuchungen [The Achilles Tendon Blood Supply - Radiological, Microradiographical and Histological Findings]. Aktuelle Traumatologie, 31, 241-244. doi:10.1055/s-2001-18729.
Paessler, H. H. (1998). Die percutane Achillessehnennaht [Percutaneous repair of Achilles tendon]. Sportorthop Sporttraumatol, 14, 93.
Riedl, S., Sandberger, L., Nitschmann, K., & Meeder, P. J. (2002). Die Naht der frischen Achillessehnenruptur Vergleich der offenen mit einer perkutanen Nahttechnik [Suture of fresh Achilles tendon rupture. Comparison of open with percutaneous suture technique]. Chirurg, 73, 607-614. doi:10.1007/s00104-002-0452-2.
Soma, C. A., & Mandelbaum, B. R. (1995). Repair of acute Achilles tendon ruptures. Orthopedic Clinics of North America, 26, 239-247.
Strauss, E. J., Ishak, C., Jazrawi, L., Sherman, O., & Rosen, J. (2007). Operative treatment of acute Achilles tendon ruptures: An institutional review of clinical outcomes. Injury, 38, 832--838. doi:10.1016/j.injury.2006.06.005.
Webb, J. M., & Bannister, G. C. (1999). Percutaneous repair of the ruptured tendo achillis. Journal of Bone and Joint Surgery British Volume, 81, 877–880. doi:10.1302/0301-620X.81B5.9784.
Wolff, K. S., Wibmer, A. G., Binder, H., Grissmann, T., Heinrich, K., Schauer, S., Nepp, R., Rois, S., Ritschl, H., Teufelsbauer, H., & Pretterklieber, M. L. (2012). The avascular plane of the Achilles tendon: A quantitative anatomic and angiographic approach and a base for a possible new treatment option after rupture. European Journal of Radiology, 81, 1211-1215. doi:10.1016/j.ejrad.2011.03.015.
Wren, T. A., Lindsey, D. P., Beaupré, G. S., & Carter, D. R. (2003). Effects of creep and cyclic loading on the mechanical properties and failure of human Achilles tendons. Annals of Biomedical Engineering, 31, 710-717. doi:10.1114/1.1569267.