SLR - January 2010 - Mher Vartivarian
Reference:
Pajala A, Kangas J, Siira P, Ohtonen P and Leppilahti J. (2009). Augmented compared to nonaugmented surgical repair of a fresh total achilles tendon rupture: A prospective randomized study. The Journal of Bone and Joint Surgery, 91, 1092-1100.
Scientific Literature Reviews
Reviewed by: Mher Vartivarian, DPM
Residency Program: Kaiser Permanente -Vallejo
Podiatric Relevance:
Achilles tendon ruptures are common and are generally surgically managed. Surgical options may include suturing without augmentation, suturing with augmentation, and percutaneous re-approximation. There are very few studies comparing augmented and non-augmented Achilles tendon repair, and only one prospectively evaluates outcomes (comparing end-to-end repair versus augmentation using the plantaris tendon).
Methods:
In this prospective study, sixty patients were randomized for surgical correction using either end-to-end repair with the Krackow suture technique (32 patients) or repair using augmentation with a down-turned gastrocnemius fascia flap described by Silfverskiold (28 patients). The exclusion criteria included age > 65 years old, ruptures that were greater than 7 days old, local steroid injections within 6 months of the rupture, open rupture, integumentary compromise near the rupture site, and patients living abroad.
All surgeries were performed within 48 hours of injury by the same surgeon, using spinal anesthesia in the prone position, with the use of a tourniquet. The incision was placed posteromedially from the midline. Two 0-gauge PDS and 2-0 Vicryl sutures were used for the Krackow method. The augmentation method used a 10mm wide gastrocnemius aponeurosis flap sutured to the distal part of the tendon using 2-0 Vicryl.
Post-operative care included a below-knee dorsal brace allowing plantarflexion, but not dorsiflexion beyond neutral. Twenty kilograms of weight bearing was allowed for 3 weeks, followed by half weight-bearing at 3-6 weeks, and full weight bearing after 6 weeks. Patients were seen at 3, 6, 12, and 52 weeks, and the clinical outcome was assessed at 12 and 52 weeks. Evaluation was based on pain, stiffness, weakness, footwear restrictions, subjective outcomes, and objective outcomes (isokinetic and isometric muscle function). The isokinetic muscle strengths were measured at three different speeds.
Results:
The average duration of surgery was 77 +/- 12.1 minutes for the augmented group and 52 +/- 8 minutes for simple repair group. Length of incisions were 18 +/- 1.3 cm and 11 +/- 1.4 cm, respectively. There were three re-ruptures in each group and two deep infections, both in the augmented group.
The overall outcome for the simple repair group was excellent for 63%, good for 27%, and 10% had rerupture. The augmented repair group had 56% excellent scores, 24% good, and 5% early failure. The results were not statistically significant.
At 12 months, there was no difference between the groups in subjective results which included pain, stiffness, subjective weakness, footwear restrictions, or range of ankle motion. The isokinetic and isometric strength showed deficits, but the results were not significantly different between the 2 groups, however within each group, there was a significant difference between 3 and 12 months. Tendon elongation occurred in both groups and correlated significantly with the isokinetic and isometric deficits in the simple repair group.
Conclusions:
The augmented repair method did not have any advantage over a simple repair method which employed a Krackow suture technique.