Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

513. Percutaneous Achilles Tendon Repair: Perspective 1

Karen M. Sutton, Sandra L. Tomak, and Lamar L. Fleming

DEFINITION

images Achilles tendon ruptures typically occur about 2 to 6 cm proximal to the tendon's insertion site on the calcaneus.

images This injury is relatively common among both highperformance athletes and the recreational athlete, particularly the “weekend warrior.”

images Ruptures occur most often in men between 30 and 50 years of age.

ANATOMY

images Tendinous portions of the gastrocnemius and soleus muscles coalesce to form the Achilles tendon (FIG 1).

images The plantaris muscle is a distinct entity medial to the Achilles tendon.

images The soleus tendon originates as a band proximally on the posterior surface of its muscle, and the gastrocnemius tendon emerges from the distal margin of the muscle bellies.

images The length of the tendon formed from the gastrocnemius and soleus range from 11 to 26 cm and 3 to 11 cm, respectively.

images

FIG 1  Merging of the gastrocnemius and soleus muscles to form the Achilles tendon.

images Viewed from proximal to distal, the Achilles tendon progressively becomes thinner in its anteroposterior dimensions, particularly from 4 cm proximal to the calcaneus to its insertion on the calcaneus.4

images Ninety-five percent of the tendon collagen is type I collagen; a small percentage is elastic. Seventy percent of the dry weight of the tendon is collagen.17

images The blood supply to the Achilles tendon arises from the musculotendinous junction, the osseous insertion, and multiple mesotenal vessels.

images The tendon is most poorly vascularized at its midportion, receiving its blood supply from the paratenon.20 The mesotenal vessels decrease in number 2 to 6 cm proximal to the osseous insertion.21

images The Achilles tendon receives much of its nutrition from the tenosynovial fluid that bathes the tendon and is contained within the paratenon.

PATHOGENESIS

images Ruptures occur most commonly during athletic activities.

images Both hyperpronation and cavus foot alignment are associated with Achilles tendon injuries. The cavus foot is thought to place more stress on the lateral side of the Achilles tendon and to absorb shock poorly.19

images Inconsistent training, including sudden increases in training intensity; excessive training; training on hard surfaces; and running on sloping, hard, or slippery roads have been implicated in Achilles tendon problems.19

images Mechanisms of injury, leading to eccentric loads on the Achilles tendon, include pushing off with the weight-bearing forefoot while extending the knee, unexpected dorsiflexion of the ankle, or violent dorsiflexion of a plantarflexed foot.1

images With normal aging, the Achilles tendon decreases in cell density, collagen fibril diameter and density, and fiber waviness. These changes may make the aging athlete more susceptible to injury.21

images Spontaneous rupture of the Achilles tendon has been associated with corticosteroid use,11 inflammatory or autoimmune conditions,6,15 collagen abnormalities,5 infectious diseases,2 neurologic conditions,15and fluoroquinolone use.18

NATURAL HISTORY

images Chronic Achilles tendon injuries typically result in the patients's inability to complete everyday tasks such as climbing stairs.8

PATIENT HISTORY AND PHYSICAL FINDINGS

images The patient reports sudden pain in the affected leg.

images Some patients recall an audible pop or

images With Achilles tendon ruptures, patients occasionally experience a sensation as though they were “kicked” or “hit” in the injured calf.

images Patients report an inability to bear weight and have weakness of the affected lower extremity.

images Physical examination should include the following:

images Palpation of gap: Palpate along the posterior aspect of the lower leg, and a gap may be felt along the course of the tendon.

images Positive: appreciable gap

images Thompson test: With the patient prone, squeeze the proximal portion of the calf.

images Positive: no plantarflexion of the ankle

images False-positive results may be obtained with an intact plantaris tendon.

images Knee flexion test: With the patient prone, have him or her actively flex both knees to 90 degrees.

images Positive: asymmetric resting tension of both ankles; the affected foot may even fall into neutral or dorsiflexion.

images Needle test: Insert a hypodermic needle into the calf medial to the midline and 10 cm proximal to the insertion of the tendon. The ankle is put through passive range of motion.

images Positive: the needle points proximally on dorsiflexion.

images This test is usually only performed if there remains a high index of suspicion with the other tests being equivocal.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Plain radiographs (rarely required in evaluation of Achilles tendon ruptures)

images In a lateral radiograph, the fat-filled triangular space (ie, Kager's triangle) anterior to the Achilles tendon and between the posterior aspect of the tibia and the superior aspect of the calcaneus loses its regular configuration.

images MRI (FIG 2) (rarely required in evaluation of Achilles tendon ruptures)

images T1and T2-weighted images in the axial and sagittal planes should be used to evaluate Achilles tendon ruptures.

images

FIG 2  T2-weighted MRI scan displaying a complete rupture of the Achilles tendon about 5 cm proximal to the insertion site on the calcaneus.

images T1-weighted: a complete rupture of the Achilles tendon is identified as a disruption of the signal within the tendon.

images T2-weighted: a complete rupture is demonstrated as a generalized increase in signal intensity, and the edema and hemorrhage at the site of the rupture are seen as an area of high signal intensity.10

images Ultrasound (useful because it can be performed in the office setting)

images Rupture seen as an acoustic vacuum with thick irregular edges

images May also be used for postoperative evaluation to assess the structure of the tendon and integrity of repair14

DIFFERENTIAL DIAGNOSIS

images Typically, rupture of the Achilles tendon does not conjure up a differential diagnosis.

images Because four other muscles plantarflex the ankle, Achilles tendon ruptures may be initially mistaken for ankle sprains; although increasingly less common, it has been reported that up to 20% of Achilles tendon ruptures may be missed by the first doctor to examine the patient.9

NONOPERATIVE MANAGEMENT

images Equinus short-leg cast or plantarflexed cam boot for 6 to 8 weeks

images At 6 to 8 weeks, start gentle range-of-motion exercises.

images A heel lift is used in the transition to wearing normal shoes.

images The patient may return to running in 4 to 6 months.

images Considered for elderly or sedentary patients, poor surgical candidates (vascular compromise and/or poor skin quality), or patients favoring nonoperative treatment

images The rerupture rate after nonoperative management is about 12.1%, compared with the rerupture rate for surgical repair, which is only 2.2%.12

SURGICAL MANAGEMENT

images In our hands, percutaneous repair is reserved for acute tears, a minimal tendon gap, and compliant patients.

images Advantages of percutaneous repair are as follows:

images Low risk of wound complications

images Preservation of blood supply for tendon healing

images Performed as outpatient procedure

images Requires only local anesthetic

images Maintenance of tendon length

images Earlier return to function when compared to closed treatment

images Disadvantages include:

images Potential sural nerve injury

images Higher rerupture rate versus open repair

images Limited patient population

images Need for compliance postoperatively

images Percutaneous repair is contraindicated in chronic tears, tendon gap, noncompliant patients, and high-level athletes (relative).

Positioning

images Prone position

images No tourniquet

images Injured foot in about 25 degrees of plantarflexion

Approach

images Percutaneous

TECHNIQUES

PERCUTANEOUS ACHILLES TENDON REPAIR

images The repair is performed under local anesthesia (TECH FIG 1.)

images A size 0 monofilament polydioxanone suture with two Keith needles, one on either end, is used.

images Medial and lateral stab incisions are made on either side of the Achilles tendon using a no. 15 blade in the following locations: at the level of the rupture; 2.5 cm and 5 cm above the rupture; and 2.5 cm below the rupture. A total of eight stab incisions are made (TECH FIG 2).

images The subcutaneous tissues at each incision site are spread using a hemostat.

images Beginning at the most proximal lateral wound, the needle is passed transversely, and the suture is then manipulated until equal lengths are established on either side (TECH FIG 3).

images The suture is then advanced distally from both sides through the ipsilateral proximal incisions in a crisscross fashion through the tendon at 45-degree angles (TECH FIG 4).

images The previous step is repeated at both 5 cm and 2.5 cm proximal to the rupture (TECH FIG 5).

images The suture, now emerging at the level of the rupture, is then tensioned to ensure that ist is secured in the proximal Achilles tendon stump.

images The suture is then advanced distally across the rupture site, in a fashion similar to the previous step (TECH FIG 6).

images The lateral suture is passed through the ipsilateral incision transversely, from lateral to medial, where the ends of the sutures are pulled simultaneously, and then tied; closing the tendon gap.

images A hemostat is used to bury the knot and to be sure there is no skin puckering at any of the incision sites.

images Staples are placed to approximate the skin.

images

TECH FIG 1  Local anesthetic used for the procedure.

images

TECH FIG 2  Incision locations: at the level of the tear, 2.5 cm and 5 cm above the tear, and 2.5 cm below the tear.

images

TECH FIG 3  The needle is passed transversely, and the suture is manipulated until equal lengths are obtained.

images

TECH FIG 4  Diagram outlining the technique used for percutaneous repair of an acute Achilles tendon rupture. D. The finished repair. (Adapted with permission from Tomak SL, Fleming LL. Achilles tendon rupture: An alternative treatment. Am J Orthop 2004;33:9–12.)

images

TECH FIG 5  Crisscross fashion to advance the suture distally through the tendon at 45 degree angles.

images

TECH FIG 6  Suture is advanced distally across the rupture site.

images

POSTOPERATIVE CARE

images Throughout the rehabilitation period: light active dorsiflexion, muscle strengthening, proprioception exercises, stationary cycling with heel push, soft tissue treatments

images For the first 2 weeks: immobilization and non–weightbearing of the foot and ankle in an adjustable boot locked in 20 degrees of plantarflexion (FIG 3). Gentle plantigrade movement of the foot, straight leg raises, and knee range of motion are begun.

images Week 2: the boot is adjusted to 10 degrees of plantarflexion.

images Week 4: Orthosis is adjusted to neutral; partial weight bearing is initiated.

images

FIG 3  Orthosis used for rehabilitation.

images Week 6: Full weight bearing is permitted.

images Week 8: The foot is placed in a shoe with a heel lift.

images Month 3: The patient starts closed-chain exercises, cycling, and elliptical trainer.

images Month 6: Running, jumping, and sports activities may be resumed.

OUTCOMES

images Retrospective review of 10 consecutive patients with acute Achilles tendon ruptures22:

images No reruptures

images No major complications

images One sural nerve injury

images Mean return to full activity at 6.1 months

images American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot rating: average score 94

images Mean difference of 1.58 cm in calf circumference, with the involved leg having the smaller circumference

images Mean plantarflexion peak torque of the uninvolved leg and the involved leg of 67.8 and 52.8 foot-pounds, respectively (at a speed of 30 degrees per second)

images Comparative studies of percutaneous versus open Achilles tendon repair

images Lim et al13 reported significantly fewer wound complications/infections with percutaneous Achilles repair when compared to open repair. There was no significant difference between the two groups with respect to the duration of the immobilization, return to functional activity, and other complications.

images Haji et al7 reported: Mean operative times of 28.5 minutes and 25.9 minutes (statistically significant) and rerupture rates of 2.6% versus 5.7% (not statistically significant), respectively for percutaneous versus open repair.

images Cretnik et al3 noted significant increased tendon thickness and increased loss of dorsiflexion in the openly treated patients.

images Out of 133 percutaneously repaired tendons, 1 patient (0.7%) sustained a complete rerupture, and 4 patients (3%) sustained a partial rupture, compared with 3 (2.8%) and 0 patients, respectively, in the open repair group.

images Sural nerve injury occurred in 6 patients (4.5%) in the percutaneous repair group and 3 patients (2.8%) in the open repair group.

images Wagnon and Akayi23 compared the Webb-Bannister percutaneous technique to open repair.

images The open repair group had an 8.6% incidence of wound complications (no wound dehiscence occurred in the percutaneous repair group).

images Two patients out of 35 experienced rerupture after open repair; 1 patient (out of 22) experienced a rerupture after percutaneous repair.

images Patients returned to work a mean of 4 months after open repair and 3.75 months after the Webb-Banister percutaneous repair.

images No sural nerve complications occurred.

COMPLICATIONS

images Sural nerve injury

images Palpable suture knot which may necessitate excision

images Rerupture

images Deep venous thrombosis3

REFERENCES

1.     Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon. A study of 92 cases. Acta Chir Scand 1959(suppl):239.

2.     Arner O, Lindholm A, Orell S. Histologic changes in subcutaneous rupture of the Achilles tendon. A study of 74 cases. Acta Chir Scandinavica 1958–1959;116:484–490.

3.     Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: A comparative study. Am J Sports Med 2005;33:1369–1379.

4.     Cummins E, Anson B, Carr B, et al. The structure of the calcaneal tendon (of Achilles) in relation to orthopaedic surgery. With additional observations on the plantaris muscle. Surg Gynecol Obstet 1946;83:107–116.

5.     Dent CM, Graham GP. Osteogenesis imperfecta and Achilles tendon rupture. Injury 1991;22:239–240.

6.     Dodds WN, Burry HC. The relationship between Achilles tendon rupture and serum uric acid level. Injury 1984;16:94–95.

7.     Haji A, Sahai A, Symes A, et al. Percutaneous versus open tendo achillis repair. Foot Ankle Int 2004;25:215–218.

8.     Hattrup SJ, Johnson KA. A review of ruptures of the Achilles tendon. Foot Ankle 1985;6:34–38.

9.     Inglis AE, Scott WN, Sculco TP, et al. Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am 1976;58:990–993.

10. Kabbani YM, Mayer DP. Magnetic resonance imaging of tendon pathology about the foot and ankle. Part I. Achilles tendon. J Am Podiatr Med Assoc 1993;83:418–420.

11. Kennedy JC, Willis RB. The effects of local steroid injections on tendons: A biomechanical and microscopic correlative study. Am J Sports Med 1976;4:11–21.

12. Kocher MS, Bishop J, Marshall R, et al. Operative versus nonoperative management of acute Achilles tendon rupture: Expected-value decision analysis. Am J Sports Med 2002;30:783–790.

13. 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.

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

15. Maffulli N, Irwin AS, Kenward MG, et al. Achilles tendon rupture and sciatica: A possible correlation. Br J Sports Med 1998;32:174–177.

16. Majewski M, Rohrbach M, Czaja S, et al. Avoiding sural nerve injuries during percutaneous Achilles tendon repair. Am J Sports Med 2006;34:793–798.

17. O'Brien M. Functional anatomy and physiology of tendons. Clin Sports Med 1992;11:505–520.

18. Royer RJ, Pierfitte C, Netter P. Features of tendon disorders with fluoroquinolones. Therapie 1994;49:75–76.

19. Saltzman CL, Tearse DS. Achilles tendon injuries. J Am Acad Orthop Surg 1998;6:316–325.

20. Schmidt-Rohlfing B, Graf J, Schneider U, et al. The blood supply of the Achilles tendon. Internat Orthop 1992;16:29–31.

21. Strocchi R, De Pasquale V, Guizzardi S, et al. Human Achilles tendon: Morphological and morphometric variations as a function of age. Foot Ankle 1991;12:100–104.

22. Tomak SL, Fleming LL. Achilles tendon rupture: An alternative treatment. Am J Orthop 2004;33:9–12.

23. Wagnon R, Akayi M. The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: A functional and MRI assessment. J Foot Ankle Surg 2005;44:437–444.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!