SLR - December 2017 - Sandeep P. Patel
Debridement and Functional Rehabilitation for Achilles Tendon Infection Following Tendon Repair
Reference: Seung HB. Et al. Debridement and Functional Rehabilitation for Achilles Tendon Infection Following Tendon Repair. The Journal of Bone and Joint Surgery, 2016;98:1167-7.
Scientific Literature Review
Reviewed By: Sandeep P. Patel, DPM
Residency Program: Southern Arizona VA Health Care System, Tucson, AZ
Podiatric Relevance: Achilles tendon rupture is a common injury, and surgical repair poses a risk of infection reported between 0.2 percent and 3.6 percent. Infected Achilles tendon after tendon repair is difficult to treat due to poor vascularity and thin surrounding tissue. Treatment goals should include controlling local infection and restoring functional plantarflexion. Various treatment options include tendon transfers and free flaps for wound coverage, etc. However, one alternative method that has shown a great deal of success includes radical debridement of the infected tissue followed by functional treatment without tendon transfers.
Methods: Retrospective review of all medical records of fifteen tertiary referral patients with postoperative deep infection of Achilles tendon occurring between January 2007 to December 2012. There were thirteen male patients and two female patients with a mean age of 53 years. There were eight patients with right-side involvement and seven patients with left-side Achilles tendon repair involvement with a mean follow-up of 33 months. In the first stages of surgical procedure, radical debridement of the Achilles tendon was performed with removal of all devitalized tissue until healthy tissue was exposed at the margin. After resection of the infected tendon, interrupted side-to-side suturing of the tendon sheath was performed to reduce dead space with a suction drain tube. No patient received skin graft or flap coverage. Postoperatively, IV antibiotics were given for 15 days and then oral antibiotics administered for 16 days based on the pathogen. Patients were placed in a splint for the first two weeks then in a below-the-knee walking brace for the next four weeks. Functional, laboratory and radiographic evaluations were performed in each of these patients.
Results: In a mean time of 17 days after debridement, infection signs, such as discharge from the wound, local redness and local warmth resolved. The wound had healed, and sutures were removed at a mean of 17 days following wound repair. In comparing passive range of motion of the ankle joint compared with the contralateral uninvolved side, there was a subjective improvement of overall function. All patients reported 80 to 100 percent in overall subjective function following the surgical procedure. Ability to perform a single limb heel raise was achieved in 10 patients. Radiographically, this study identified a scar healed Achilles tendon similar in shape and continuity on postop ultrasonography examination with a mean of 27 months.
Conclusions: This study is unique because it offers an alternative to in treating postoperative infection of Achilles tendon with radical debridement of infected tissue with vigorous rehabilitation without tendon transfers, skin graft or flap coverage. Some limitations of the study included small number of patients and no comparative study with other surgical approaches. Overall, the study determined that complete debridement of the infected tissue is most important following Achilles tendon repair.