SLR - August 2018 - Hayley E. Iosue

Infection and Rerupture After Surgical Repair of Achilles Tendons

Reference: Jildeh TR, Okoroha KR, Marshall NE, Abdul-Hak A, Zeni F, Moutzouros V. Infection and Rerupture After Surgical Repair of Achilles Tendons. Orthop J Sports Med. 2018 May 25;6(5):2325967118774302. doi: 10.1177/2325967118774302. eCollection 2018 May.

Scientific Literature Review

Reviewed By: Hayley E. Iosue, DPM
Residency Program: Beth Israel Deaconess Medical Center, Boston, MA

Podiatric Relevance: Achilles tendon ruptures are relatively common injuries seen in podiatric clinical practice, accounting for approximately 20 percent of all large tendon injuries. Ruptures can be treated conservatively or surgically. Some literature has shown decreased rerupture rates but increased infection with surgical repair of an acute Achilles tendon rupture. This study aimed to determine risk factors associated with infection and rerupture after primary repair of Achilles tendon ruptures.

Methods: This is a level III retrospective review of 423 patients who underwent surgical treatment of Achilles tendon ruptures at two hospitals. The CPT code of 27650 (Achilles tendon repair) was used to identify these patients. Patients were excluded if they were not at least two years from the date of surgery. Demographic data of BMI, age, sex and race were recorded for each patient along with mechanism of injury. Patient risk factors of previous steroid injection, smoking status, alcohol use and diabetes mellitus were also identified. Lastly, surgical data, including laterality, type of skin preparation, estimated blood loss, tourniquet time and operative time, were reviewed. Data was described as means and standard deviations as needed, and risk factor data was assessed with a Wilcoxon rank-sum and Fisher exact tests.

Results: A total of 423 patients were analyzed in this study. The overall infection rate was 2.8 percent. The rate of deep infection was 1 percent, and superficial infection was 2 percent. The mean time between surgery and superficial infection was 30 days. Surgical risk factors found to be associated with increased deep surgical site infections were longer tourniquet times and higher estimated blood loss. Compared to nonsmokers, current and previous smokers had increased rates (40 percent) of superficial surgical site infections. The overall rate of rerupture was 1 percent. The mean time between surgery and rerepture was 38 days. There was a trend, although not statistically significant, of longer operative times and longer tourniquet times being associated with higher rates of rerupture.  

Conclusion: This studied confirmed Achilles tendon repairs are associated with a low risk of infection and rerupture. Longer tourniquet times, larger amounts of blood loss and smoking history have an increased risk of surgical site infections, while longer tourniquet and operative times were associated with increased incidence of rerupture. These factors have been shown to increase tissue hypoxia and inflammation, possibly contributing to the increased complications. The authors also discussed how longer tourniquet and operative times may be associated with injury severity, case complexity or lack of surgeon experience, all of which can contribute to postoperative complications. This data is important for surgeons to recognize and utilize while evaluating their patient and the injury and when developing and executing a surgical plan, as some of these factors can be modified by the surgeon. 

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