SLR - May 2020 - Abigail Dunklee Rappa

Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results as Compared with Acute Repair

Reference: Maffulli N, D’Addona A, Maffulli GD, Gougoulias N, Oliva F. Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results as Compared with Acute Repair. Am J Sports Med. 2020 Mar 16.

Scientific Literature Review

Reviewed By: Abigail Dunklee Rappa, DPM
Residency Program: NewYork Presbyterian/Queens – Queens, NY

Podiatric Relevance: Podiatric physicians frequently see patients with Achilles tendon ruptures. At times, these injuries present acutely; however, timing of presentation after the initial injury can be variable. According to this article, >20 percent of acute Achilles tendon ruptures are either misdiagnosed or do not seek immediate medical care. As a result, podiatric physicians may have difficulty forming a surgical plan for delayed cases. Historically, delayed Achilles rupture has been treated with open repair. Percutaneous repair has shown to have reduced infection rates and wound complications. This article hypothesized that percutaneous repair can be used to treat delayed presentation of Achilles tendon rupture with similar outcomes to those who underwent the same repair for acute injuries.

Methods: This level three comparative study included patients who were prospectively recruited  >18 years old with ruptures at the noninsertional portion of the Achilles tendon. Patients with delayed presentation (surgery 14-30 days after injury) were matched in age (+/- 2 years), sex, and level of activity to patients with acute presentation (surgery within 14 days of injury). Surgical technique consisted of six stab incisions which was sutured in a Bunnel fashion proximally and a modified half-Kessler configuration distally. Postoperatively both groups underwent the same rehabilitation until full weightbearing was achieved. At each follow up, tendon elongation, functional outcome, return to sports, calf circumference, muscle power, and surgical complications were assessed. 

Results: At 12 months postoperatively, the delayed and acute presentation groups had similar results for tendon elongation, functional outcome, and return to physical and sports activities. Regarding physical performance 12 months post-operatively compared to pre-injury, 62 percent of the delayed group and 52 percent in the acute group stated they were improved or the same. There were no wound complications or infections. Two patients in the acute group had prominent knots that were removed ten weeks postoperatively. Both groups experienced preoperative (four in the delayed group and three in the acute group) dyesthesia and postoperative dysesthesia (one in each group) in the distribution of the sural nerve. Neither group experienced re-rupture. 

Conclusions: This study demonstrates that percutaneous repair for the treatment of delayed presentation of Achilles tendon rupture had similar results compared with acute repair for the same injury. When comparing tendon elongation, functional outcome, and return to physical and sports activity, 62 percent of the delayed group and 52 percent in the acute group were either the same or improved compared to pre-injury outcomes. Historically if a patient presented with a delayed Achilles tendon rupture, they were treated with an open repair and often presumed that augmentation was necessary. Percutaneous procedures have gained popularity to reduce wound complications, infection rates, and promote quick recovery / return to activity. Additionally, in this study, they were able to demonstrate tendon to be successfully approximated with a secure suture configuration without any augmentation, at 30 days post-injury. The results of this study offer an alternative treatment modality for delayed Achilles tendon ruptures. Foot and ankle surgeons can consider percutaneous treatment and expect similar results to patients who were treated open. 

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