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Keywords: Achilles tendon, percutaneous repair
Percutaneous repair of a ruptured Achilles tendon is a safe and reliable method of treating such injuries in patients with low sporting requirements. It has a lower incidence of wound complications compared with open techniques but a slightly higher incidence of re-rupture. Sural nerve injury is avoidable by careful placement of the incisions
The Achilles tendon is the strongest tendon in the human body with a tensile strength in the order of 50-100 N/mm. (1,2) It is formed from the joining of the two tendons of soleus ( dorsally) and gastrocnemius (ventrally).(2) Despite its strength, the Achilles tendon is the most frequently ruptured tendon in the body. Tendon fibres begin to disrupt after a length increase of 3-4% and rupture after an increase of 8%. Rupture usually occurs between 2-6 cm of its insertion into the superior surface of the calcaneus, a relatively hypovascular area. (3,4) The major blood supply to tendons is from the mesotendon, and the largest supply is from the anterior mesentery. (5) The greatest risk of tendon rupture is when the tendon is obliquely loaded, the muscle is contracting maximally and tendon length is short. (6) This usually occurs as a result of pushing off with the foot against resistance and occurs most frequently in males in the fourth decade.
The aetiopathogenesis of Achilles tendon rupture is unknown, but histological evidence of degeneration is relatively common. McMaster suggested that normal tendons do not rupture. (6) Tallon et al showed that both tendinopathic and ruptured tendons had a greater degree of histological evidence of degeneration compared with normal tendons, and that the degree of degeneration in the ruptured group was statistically greater than in the tendinopathic group.(7) Achilles tendon rupture has also been associated with steroid use, rheumatoid arthritis, renal transplantation, and quinolone antibiotic usage. (8-11)
Non-operative treatment of Achilles tendon rupture was described as early as 1575 by Ambroise Pare (12) who treated these injuries with bandages but noted a poor outcome. Treatment with an equinus cast has a reported re-rupture rate of 17%. (13) Closed management in an equinus cast will result in significant loss of strength and power in the calf muscle. (14) Open surgical management of patients with ruptured Achilles tendons allows accurate apposition of the ruptured tendon ends, earlier motion, has a low risk of re-rupture, but is associated with a significant rate of wound healing problems. Hockenbury and Johns showed that a Ma and Griffiths percutaneous repair provides 50% of the initial repair strength of an open Bunnell suture repair in 10 cadaveric specimens. (15) Nevertheless, percutaneous techniques allow a secure repair to be achieved. Because of the greater strength and despite the risks of wound complications, open repair is generally the treatment method of choice for young fit patients wishing to return to sporting activities. (16)
Bradley and Tibone reported a higher risk of re-rupture in percutaneous repairs compared with open repair. Lim et al more recently, however, in a prospective multicentre randomised controlled study comparing open and percutaneous repair techniques reported a higher rate of re-rupture in cases treated by an open technique (6% vs 3%, using a percutaneous technique). The difference, however, was not statistically significant. Bradley and Tibone compared 15 patients treated with a gastrocsoleus fascial graft and 12 patients treated using a percutaneous technique. Strength, power and endurance measurements of both groups showed no statistical difference. Two of 12 (13%) percutaneous repairs re-ruptured up to a follow-up of 1.8 years, compared with none in the open repair group (follow-up 4.6 years). They recommended percutaneous repair in the recreational athlete and open repair in the competitive athlete. Martinelli reported 30 cases of percutaneous repair of Achilles tendons in which all athletes returned to pre-injury levels of sport by 150 days post-injury.
Wound healing problems associated with open repair can be reduced by using percutaneous techniques, and the incidence of adhesion of the skin to the underlying tendon, as can occur in open repair, is also lower with percutaneous techniques. (13,17)
Kauranen and Leppilahti reviewed the motor performance of 90 patients following operative repair (mean of 3.1 years post surgery) of a ruptured Achilles tendon. They observed the performance of the unloaded lower extremity and compared the operated limbs with the unoperated side, and to age and gender-matched control subjects. There was no statistical difference between any of the groups, and they concluded that the motor performance of the unloaded lower limb had fully recovered in the tested parameters.
Several percutaneous repair techniques have been described. (13,20-22) Ma and Griffith described a technique of percutaneous repair of the Achilles tendon in 18 patients using stab incisions over the tendon. (20) The suture was passed through stab incisions and crisscrossed through the tendon.
They reported an incidence of sensory disturbance and one case of sural nerve entrapment. Hockenbury and John, noted sural nerve entrapment in 3 of 5 cases treated using a percutaneous technique in cadaveric specimens with divided Achilles tendons. (5)
Gorschewsky et al described a technique using barbed suture wires passed from proximal to distal to pull the retracted proximal stump distally and approximate the ruptured tendon ends. Fibrin glue was then applied to the repair. The wires were removed at 3 weeks. At one year follow-up in 20 patients there was one re-rupture and no other complications. (21)
Webb and Bannister described a new percutaneous technique that reduced the potential risk to the sural nerve by placing the proximal of the incisions to the medial side, away from the nerve. (13) We describe a percutaneous technique of repair of the ruptured Achilles tendons similar to that described by Webb and Bannister. (13)
The diagnosis is generally made clinically. Patients will often report that they felt as though they had been struck at the back of the heel and may have heard a snapping sound. They are usually unable to weight bear on the affected limb because of pain and/or weakness. If examined shortly after the injury, there is usually a palpable defect in the Achilles tendon. If some time has elapsed since tendon rupture, the diagnosis can be more difficult, as the gap fills in with oedema and palpation is unreliable. Various tests can be employed to aid diagnosis. (23-25) The calf squeeze test involves the examiner gently squeezing the patient’s calf muscles with the palm of their hand. (23) If the Achilles tendon is intact, the ankle plantar flexes. If the Achilles tendon is torn, the ankle remains still, or only minimally plantar flexes. The Matles’ test can also be used. (24) It involves flexing the patient’s knee to 90 degrees with the patient prone. If the foot falls into neutral or dorsiflexion, a ruptured Achilles tendon is diagnosed. Both tests are performed on the injured and uninjured sides for comparison. The needle test is accurate, but uncomfortable for the patient and, therefore, used infrequently by us. We do not routinely use imaging to diagnose a ruptured Achilles tendon.
The neurovascular status of the limb is assessed, in particular the sensation over the distribution of the sural nerve, and documented. The risks of surgery, including sural nerve injury, re-rupture, wound infection and breakdown, are discussed with the patient when informed consent is obtained. General or regional anaesthesia can be utilised, our preferred method of anaesthesia is local anaesthesia with the patient prone during the procedure.
A 50:50 mixture of 10 ml of 2% lignocaine hydrochloride (Antigen Pharmaceuticals Ltd, Roscrea, Ireland) and 0.25% bupivacaine hydrochloride (Astra Pharmaceuticals LTD, Kings Langley, England) is instilled into an area of between 8 and 10 cm around the ruptured Achilles tendon. The patient is placed prone, and a pillow is placed beneath the anterior aspect of the ankles to allow the feet to hang free. The operating table is angled down 20 degrees cranially to reduce venous pooling in the feet and ankles. Both legs are prepped to allow the tension of both Achilles tendons to be compared intraoperatively. A tourniquet is not used. Three 3 cm transverse incisions are made over the Achilles tendon. The first is directly over the palpable defect. A small piece of tendon from the rupture site is removed and sent for histological examination. The other incisions are about 4 cm proximal and 4 cm distal to the first incision (Figure 1).
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The proximal incision is made to the medial side of the tendon (Figure 2) to reduce the risk of damage to the sural nerve. (13)
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The sural nerve crosses the lateral-border of the Achilles tendon about 10 cm proximal to its insertion into the calcaneus.(26) The sural nerve supplies sensation to the skin over the posterolateral aspect of the calf and over the lateral malleolus, the lateral aspect of the foot, and the fourth and fifth toes. Damage to the sural nerve will result in sensory deficit affecting the above areas and can produce a troublesome neuroma.
A small haemostat is used to free the tendon sheath from the overlying subcutaneous tissue. A 1 PDS II (Ethicon, Johnson and Johnson Intl, Brussels, Belgium) double strand suture on a long curved needle is passed transversely through the distal incision passing through the substance of the tendon and out through the same incision. (Figure 3)
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The needle is then reintroduced medially into the distal incision through a different entry point in the tendon and passed longitudinally through the tendon, to lock the tendon, and is directed towards the middle incision and out through the ruptured tendon end. (Figure 4)
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The suture that is still protruding from the distal incision is re-threaded onto the needle and reintroduced laterally into the distal incision and into the tendon. It is passed proximally through the tendon to exit from the middle incision. Traction is applied to the suture to ensure a satisfactory grip within the tendon. The same procedure is carried out for the proximal half of the ruptured tendon. (Figure 5)
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A further 1 PDS II (Ethicon, Johnson and Johnson Intl, Brussels, Belgium) double stranded suture can be placed in the tendon ends as described above in order to produce an 8-strand repair. The sutures are then tied with the ankle in neutral plantar flexion. The tension is assessed by observing the contralateral limb as the sutures are tied. The skin wounds are closed with undyed subcuticular 3/0 vicryl (Ethicon, Edinburgh, UK, EH11 4HE) suture and non adherent dressings are applied. A full Plaster of Paris cast is applied in theatre with the ankle in the equinus position.
The operated limb is elevated on a frame. The neurovascular status of the limb is assessed. Patients are usually discharged the same day following repair, after assessment by the physiotherapist. The full cast is retained for 2 weeks. At this time, patients are reviewed in the outpatient clinic where the cast is split and the wounds inspected. An anterior splint is worn with foot plantigrade for a further 4 weeks. Patients are advised to mobilise partial weight bearing initially, increasing to weight bearing as able by 4 weeks. During the period in cast, patients are advised to perform gentle isometric contractions of the gastro-soleus complex after weight bearing has become comfortable. The splint is then removed, and physiotherapy follow-up for gentle mobilisation is arranged.
Swimming and cycling can be started 2 weeks post removal of splint and patients would be expected to be full-weight bearing by 8 to 10 weeks post operation.
Table 1: Complications which can occur following a ruptured Achilles tendon
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Early (peri-operative)
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Sural nerve damage
Haematoma |
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Intermediate (<6 weeks)
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Infection
Wound healing complications |
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Late (6 weeks to 6 months) |
Re-rupture of tendon
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Complications can be early, intermediate or late and are outlined in Table 1.
Early possible postoperative complications are sural nerve damage and haematoma formation. The medial positioning of the proximal incision reduces the risk of damage to the sural nerve. Haematoma formation risk is reduced as the procedure is carried out without tourniquet so that the surgeon will be able to deal with any bleeding at the time of operation.
Intermediate superficial and deep wound infections can occur. Open repair is associated with a significant risk of wound breakdown. Percutaneous repair reduces this risk.
The most important late complication is re-rupture. In a review of reported rates of re-rupture from conservatively treated Achilles tendon ruptures, Webb and Bannister reported a median 17% risk. (13) They reported a risk of rerupture with operatively treated Achilles tendon rupture of 2.7%, from a review of the literature. Using a percutaneous technique, Webb and Bannister did not have a re-rupture at a median follow-up of 35 months in 27 patients. Bradley and Tibone reported a re-rupture rate of 13% (2/12 patients) at a follow-up of 1.8 years. (16) However, re-rupture rates of 6% have been reported for percutaneous repairs.
Table 2: Key points of rupture and repair
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Patient selection
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Prone position
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Local anaesthesia
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Incisions made to avoid sural nerve
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Four and if necessary eight strand repair
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Splintage to protect repair for total of 6
weeks
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