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Achilles Tendon: Open versus Percutaneous Repair Kevin R. Stone, M.D.

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ACHILLES RUPTURES PERCUTANEOUS REPAIR OPEN REPAIR OPEN RECONSTRUCTION WITH ALLOGRAFT

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Achilles Ruptures symptoms and goals <ul><li>Symptoms: </li></ul><ul><li>Felt like a shot – heard pop </li></ul><ul><li>Males 40-60 </li></ul><ul><li>Swollen tendon </li></ul><ul><li>Positive squeeze test </li></ul><ul><li>Palpable defect </li></ul><ul><li>Surgical Goals: </li></ul><ul><li>Complete recovery with full sports </li></ul><ul><li>Better than non operative </li></ul>

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Achilles Ruptures Percutaneous vs Open <ul><li>Percutaneous </li></ul><ul><li>Reduced risk of infection </li></ul><ul><li>Reduced risk of painful scars </li></ul><ul><li>Saves the sheath and clot </li></ul><ul><li>Less pain/shorter surgery </li></ul><ul><li>Open </li></ul><ul><li>Traditional approach with direct visualization </li></ul><ul><li>? stronger repair </li></ul>

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Achilles Percutaneous Repair Surgical Technique The proximal portion of the tendon, as identified by palpation and MRI, is captured with a #1 Tevdek suture placed transversely through the skin and the tendon and out the opposite side. Bradley et al. Amer J Sports Med 1990 18:2 188

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Achilles Percutaneous Repair This suture is then crisscrossed through the tendon, the gap at the rupture site, and finally through the distal portion of the tendon just above the calcaneus, through the skin punctures.

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Achilles Percutaneous Repair A second stitch is placed after the first one and is tied with the foot in plantar flexion. A dressing is applied and the foot is placed in a plantar flexed pre-formed padded splint.

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Percutaneous Achilles Repair

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Percutaneous Repair <ul><li>Percuataneous Cons: </li></ul><ul><li>Sural nerve injury (6.5% - 10.5%) 1 </li></ul><ul><li>Open Cons: </li></ul><ul><li>Significant wound complications/ Scar irritation </li></ul><ul><li>Infection </li></ul><ul><li>Healing time </li></ul><ul><li>Surgery time </li></ul><ul><li>1 Haji, et. al. Foot Ankle Int. Apr. 2004; Maes, et. al. Acta Orthop Belg. Apr. 2006; Landsdaal, et. al. Feb 2007. </li></ul>

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When to Perform Open Repair? <ul><li>Failed Repair/Re-rupture </li></ul><ul><li>Fracture </li></ul>

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Achilles Open Repair Beskin et al. Amer J Sports Med 1987 15:1 1

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Open Reconstruction with Allograft For 14 month old Chronic Rupture MM 05-08-2002

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The Stone Clinic Experience <ul><li>Achilles Repair n=21 (2000-current) </li></ul><ul><ul><li>Percutaneous n=16 (acute) n=1(revision) </li></ul></ul><ul><ul><li>Primary Open n=1 (calcaneal fx) </li></ul></ul><ul><ul><li>Revisions n=3: trauma post repair </li></ul></ul><ul><li>Complications: </li></ul><ul><ul><li>Sural nerve knot impingement n=1 </li></ul></ul><ul><ul><li>Death from DVT n=1 </li></ul></ul>

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Patient Example: PK <ul><li>40/Male PK </li></ul><ul><li>New R Achilles Tear 6/2006 </li></ul><ul><li>Previous L Achilles Open Repair 11/2005 </li></ul>MRI: Left Achilles – 7 months Post Open Repair

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PK: Pre-Op R Achilles Tear

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PK: 2-Months Post-op Percutaneous vs Open

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PK: L (Open) R (Percutaneous) 8 Months post-op percutaneous 15 Months post-op open

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PK: R (Percutaneous) MRI 8 Mo. Post-Op Increased tendon diameter 7mm to 15mm. Healed defect in proximal Achilles.

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Patient Example: RB <ul><li>49/Male </li></ul><ul><li>Basketball injury: L Achilles Rupture </li></ul><ul><li>Percutaneous repair 3/07 </li></ul>Pre-Op MRI

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RB: Operative Photos

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RB: 1 week PostOp

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Rehabilitation: General Considerations • Progression is based on clinical presentation • Careful monitoring of soft tissue quality • Timing considerations

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Post-operative Protection night splint ROM walker boot

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Rehabilitation: Early Progression • 0-3 wks: Non-weight bearing , night splint • 3-8 wks: gradual progression into Walker boots with full weight bearing after 6 wks • 8-12 wks: Cowboy boots with gradual wean into regular shoes using heels lifts

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Manual Treatment Early soft tissue mobilization (edema control) Mid-soft tissue mobilization

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Post-operative Rehabilitation well leg biking feet on ball bridges

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Early Rehabilitation prone on ball abduction

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Ankle PNF Mid Rehabilitation

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single leg squat single leg resistance Mid Rehabilitation

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resisted gait proprioception challenge Late Rehabilitation

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lateral leaps diagonal leap Plyometrics

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Conclusions <ul><li>Open vs. Percutaneous: </li></ul><ul><li>No statistically significant difference in re-rupture rates (1.9%-5.7%) </li></ul><ul><ul><ul><ul><ul><li>Reidl, et. al. Chirurg. Jun 2002 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rebeccato, et. al. J Foot Ankle Surg. Aug 2001 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cretnik, et. al. Wien Klin Wochenschr. 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cretnik, et. al. AJSM 2005 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Haji, et. al. Foot Ankle Int. Apr 2004 </li></ul></ul></ul></ul></ul>

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Conclusions <ul><li>Treatment: </li></ul><ul><li>Treat the lesion </li></ul><ul><li>• Treat it early with minimal tissue </li></ul><ul><li>disruption </li></ul><ul><li>• Rehabilitate the ankle </li></ul>

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Thank You