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OUTCOMES OF MINI-OPEN REPAIR TECHNIQUE FOR ACHILLES TENDON

RUPTURE

• Presenter: Wenjay Sung, DPM

• Other Authors: Jessica M. Knight, DPM, Lowell Weil, Jr., DPM, Lowell Scott Weil, Sr., DPM, and Dusty Christensen, BS.

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Disclosures

I have nothing to disclose LWJ is a consultant for Arthrex, Inc

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Overview

Purpose Methods Statistical Analysis Procedure Results Discussion

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Purpose

There is a recent report favoring non-operative treatment for acute Achilles tendon ruptures1

The consensus in the literature favors operative treatment.

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Purpose

Most studies have shown surgical intervention produces few complications and less re-rupture Athletes regain

~50% of post-injury power after tendon repair.11

32% of NFL players do not return to sport

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Purpose

More recently, a single incision (mini-open) technique has been reported2-4.

Our retrospective series aims to report outcomes using this mini-open technique over the last eight years.

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Purpose

RETROSPECTIVE CASE SERIES Level of evidence: IV (Therapeutic)

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Methods

Reviewed the medical records for 40 consecutive patients who underwent an Achilles tendon repair between January 2002 and December 2009

There were 19 patients (19 cases) who underwent a mini-open technique.

Followed for an average of 24.4 months (range 12 to 68 months).

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Methods

All patients were assessed clinically Victorian Institute of

Sports Assessment - Achilles (VISA-A) score5

Visual Analog Pain Scale (VAS)

Any post-operative complications and re-ruptures was also recorded.

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Statistical Analysis

A paired student t-test was used to determine significance between pre-operative and post-operative outcomes with p < 0.01.

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Procedure

An incision is placed ~1cm proximal to palpable dell

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Procedure

Advance the jig with inner arms along the paratenon

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Procedure

Pass the guide pins with suture through the jig designated hole-design

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Procedure

Once all sutures have been passed through, slide jig out

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Procedure

Place jig into distal part of incision and repeat prior steps

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Procedure

With foot in maximum plantarflexion, hand-tie sutures on medial and lateral side at the same time.

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Procedure

CLOSURE/CASTING

The paratenon and skin is closed with absorbable suture.

A short leg cast at 20 degrees of equinus, and the patient is instructed to be non-weight bearing with crutch assistance.

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Procedure

POST-OPERATIVE

After two weeks post operative, the patient is transitioned into a walking boot.

The gradual reduction of equinus performed utilizing removable heel lifts.

Physical therapy exercises initiated upon removal of the short leg cast.

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Results

DEMOGRAPHICS SATISFACTION

All patients returned to their previous professional or sporting activities.

All patients reported either satisfied with outcome or very satisfied.

There were thirteen males and six female with an average age of 45.2

The average follow-up examination post-operatively was 24.4 months

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Results

CLINICAL OUTCOMES

The mean VISA-A score was 92 (range, 66 to 100 points).

Average Total Score

Stiffness AM

Pain w/ Step

Stretching

Pain @ 30 min walking

Pain downstairs

Pain Heel

raises

Pain Leg

Hops

Level of Activity

Length of

Activity

92 10 10 10 10 10 10 8 25

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Results

VAS COMPLICATIONS

Average pre-operative score 5.5

Average post-operative score 0.9

Paired student t-test P < 0.01

Complications occurred in two patients (11%). One patient obtained an

stitch abscess that resolved with local wound care.

One patient had a re-rupture eight weeks post-operative after falling at a carwash. This was re-repaired the

mini-open technique.

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Discussion

Incidence of Achilles tendon ruptures 18 in 100,000 per

year and are believed to be increasing in incidence6.

At this time, debate still exists over the best treatment for this condition in regards to non-operative care, mini-open repair, percutaneous repair, and open repair of the tendon rupture7.

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Discussion

Our series using the mini-open technique has allowed for minimal complications with a high clinical outcome.

We did not experience any incidence of sural nerve injury although this has been reported in the literature with both mini-open and percutaneous repair2, 8-10

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Discussion

STRENGTHS WEAKNESSES

Validated clinical outcome measurement scale (VISA-A)

Standardized procedure

Small sample size No pre-operative

measurement other than VAS

Assessor Bias

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Discussion

Although we add to the body of evidence that the mini-open repair technique is effective and safe for Achilles tendon ruptures, more study is needed

We believe the benefits to the patient of lower morbidity, minimal minor complications, and high satisfaction are the strengths of this procedure.

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References1. Willits K et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a

multicenter randomized trial using accelerated functional rehabilitation. JBJS AM. 2010 Dec 1;92(17):2767-75. Epub 2010 Oct 29

2. Calder JDF, Saxby TS Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med 2005;39:857–859.

3. 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. 84:161-170, 2002.

4. Calder JDF, Saxby T.S. Independent Evaluation of a Recently Described Achilles Tendon Repair Technique. Foot Ankle Int. 27(2):93-6

5. Robinson JM et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35:335–341

6. Costa M.L., Macmillan K., Halliday D., Chester R., Shepstone L., Robinson A.H.N., Donell S.T. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg [Br] 2006;88-B:69-77.

7. Chiodo C, Wilson M Current Concepts Review: Acute Ruptures of the Achilles Tendon. Foot Ankle Int. 27(4):305-13

8. Ma GWC, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon. A new technique. Clin Orthop 1977;128:247–55.

9. Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21(6):475–7.

10. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon – a prospective randomised controlled study. Foot Ankle Int 2001;22(7):559–68.

11. Parekh SG et al. Epidemiology and outcomes of Achilles tendon ruptures in the National Football League. Foot Ankle Spec 2009 Dec;2(6):283-6. Epub 2009 Oct 13.

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Thank You