SLR - August 2020 - Audrey K. Alvarez

A Comparative Study of Innovative Percutaneous Repair and Open Repair for Acute Achilles Tendon Rupture: Innovative Usage of Intraoperative Ultrasonography

Reference: Lee JK, Kang C, Hwang DS, Kang DH, Lee GS, Hwang JM, Song JH, Lee CW. A Comparative Study of Innovative Percutaneous Repair and Open Repair for Acute Achilles Tendon Rupture: Innovative Usage of Intraoperative Ultrasonography. J Orthop Surg (Hong Kong). 2020 Jan-Apr; 28(1) 

Scientific Literature Review

Reviewed By: Audrey K. Alvarez, DPM
Residency Program:
DVA Puget Sound Health Care System – Seattle, WA

Podiatric Relevance: Treatment of acute Achilles Tendon ruptures are varied without a clear consensus of the best practice methods in the literature. Traditionally, acute ruptures are repaired surgically using an open technique. Although open procedure allows for direct visualization of the repair, this technique is not without risk with regards to wound healing complications and adhesions. Recently, advancements in minimally invasive percutaneous Achilles tendon repair have allowed for foot and ankle surgeons to minimize said morbidities. To improve surgeon technique and visualization, intraoperative ultrasonography has been utilized by some surgeons. This study reviews a consecutive series of 30 patients treated with either open or ultrasound guided percutaneous techniques with review of functional outcomes and complications.

Methods: A level III retrospective cohort study was performed for patients with acute Achilles tendon ruptures who received either open or ultrasound guided percutaneous repair. A total of 30 consecutive patients during a two-year period who underwent open (18 patients) or minimally invasive (12 patients) were identified. Outcomes were evaluated by using the visual analog scale (VAS) for pain, Arner-Lindholm scale, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles Tendon Total Rupture score (ATRS), time to single heel raise, bilateral calf circumferences, recovery of athletic ability and any complications including recurrent rupture, sural nerve injuries and infection. 

Results: With a two-year follow-up and normalizing across the groups for age, sex, cause of injury, location of rupture and time between injury to surgery, both groups had improvement in the Arner-Lindholm scale, AOFAS, ATRS scores without statistically significant differences. No statistically significant difference was noted between groups for time point when single heel raise was possible, differences in bilateral calf circumference, and recovery of athletic ability post repair. Aesthetic satisfaction levels were higher (p=0.001) and VAS score was lower (p=0.035) in the group treated with percutaneous repair under ultrasonography guidance. There were no cases involving sural nerve injury in either group. One patient in the percutaneous group had a re-rupture with deep space infection requiring additional surgery. 

Conclusions: There were statistically significant differences in favor of percutaneous repair via ultrasonography guidance in the areas of decreased pain and scar appearance. The authors favor what they describe to be a unique technique with intraoperative ultrasound to avoid complications commonly seen with percutaneous Achilles tendon repair including sural nerve injury and improper repair due to inadequate suture strength when the suture needle does not cross the central body of the tendon. Limitations to the study include small sample size, it’s retrospective nature, and no clear indications for the two different operative methods were set. Both open and percutaneous repairs have shown improvements, and future higher-level studies, including those including ultrasound guided repair are needed to evaluate outcomes and guide surgeon technique and treatment on these injuries. 

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