SLR - June 2014 - Colin Zdenek

Mini-Open Tenorrhaphy of Acute Achilles Tendon Ruptures

Reference: Keller A, Ortiz C, Wagner E, Wagner P, Mococain P. (2014). Mini-open tenorrhaphy of acute Achilles tendon repair: medium-term follow-up of 100 cases. The American Journal of Sports Medicine, 42: 731-736.

Scientific Literature Review

Reviewed By: Colin M. Zdenek, DPM 
Residency Program: The Western Pennsylvania Hospital, Pittsburgh, PA

Podiatric Relevance: Controversy remains in terms of operative vs. non-operative management of acute Achilles ruptures. This article analyzes the outcomes of utilizing a mini-open tenorrhaphy, coined the Dresden mini-open technique, in acute Achilles tendon ruptures.

Methods: One hundred patients diagnosed with acute Achilles tendon rupture were identified between January 2005 and August 2011 at Clinica Alemana in Santiago, Chile. 91 of the 100 patients were male. The mean follow-up was 42.1 ± 22.4 months. Tendon repair included a minimally invasive procedure utilizing a small, longitudinal, paramedial incision proximal to the rupture site to allow the gathering of sutures placed percutaneously in the distal and proximal portions of ruptured Achilles with an inexpensive suture retrieval instrument. Outcomes analyzed included time to return to work, time to return to sports, subjective satisfaction, and complications. The American Orthopaedic Foot and Ankle Society (AOFAS) score was also utilized during final follow-up visit. In addition, isokinetic tests, peak torque and total work in plantar flexion and dorsiflexion, were tested and recorded with 21 patients willing to be examined at an average mean follow-up of 24 months.

Results: 
Two patients (2 percent) had re-ruptures at two months post-operatively and five patients (5 percent) had deep venous thrombosis, all of which were male. No reports of sural nerve entrapment and wound infections were found in the study. No loss of joint range of motion was encountered when compared to the contralateral limb. The 21 patients who underwent isokinetic evaluation showed no statistically significant difference between the injured versus uninjured side when measuring peak torque in plantar flexion and dorsiflexion. The mean AOFAS score was 97.7. The mean Leppilahti score was 54.2 points (range 35-64). Mean time to return to work was 56.0 ± 15.4 days with a return to previous levels of sporting activity mean of 18.9 ± 4.4 weeks. Of note, 98 percent of patients were satisfied with their treatment.
  
Conclusions: The Dresden technique preserves the paratenon and hematoma at the rupture site which the authors believe attribute to a more physiological repair due to growth factors and inflammatory mediators present locally. The mini-open technique allows a proper retrieval of percutaneously placed sutures that help to avoid sural nerve entrapment that is not uncommonly seen with percutaneous repair alone. In addition, as opposed to open management, which tends to lead to increased infection, the minimal incision in their study had no reported infections. Despite the relatively low number of patients included in the isokinetic evaluation, no deficit in muscle strength was seen in the injured vs un-injured limb, which always has been of concern with minimally invasive surgery. They believe this technique is reproducible, inexpensive and safe for tenorrhaphy of Achilles tendon ruptures. 

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