- Email: [email protected]
Repair of Achilles Tendon Rupture Under Endoscopic Control
Repair of Achilles Tendon Rupture Under Endoscopic Control Athanasios P. Fortis, Ph.D., Anastasios Dimas, Ph.D., and Andreas A. Lamprakis, M.D.
Purpose: To evaluate the functional outcomes and complications after endoscopically assisted percutaneous repair of Achilles tendon rupture. Methods: An arthroscopically assisted percutaneous repair was performed in 20 patients between the ages of 28 and 47 years. Two patients were suffering from a long-standing rupture. Follow-up was 2.5 years. Evaluation entailed Merkel’s scale for pain, functional load (weight) bearing capacity, and the heel raise test. For statistical analysis, a random effects Poisson regression model was used. Results: All patients achieved good to excellent outcomes. The median score on Merkel’s scale was 600. All patients were able to stand on the tiptoe of the operated leg and none had limitations placed on their daily activities. A 12% decrease in maximum torque and 16.5% decrease in work performance of the injured side were noted. There was no statistical significant difference in the heel raise test between the operated and non-operated leg. No wound problems, re-ruptures, or infections were reported. Two patients (10%) had sural neuralgia; in 1 case, it subsided without further treatment. Conclusions: Endoscopy in percutaneous Achilles tendon repair is useful in determining the initial gap and providing adequate apposition of the tendon ends. It is a safe technique with good outcomes and minimal complications. Despite its promising results, potential problems include sural neuralgia and some decrease in strength. Level of Evidence: Level IV, therapeutic case series. Key Words: Achilles tendon rupture—Endoscopy— Percutaneous repair.
A
pproximately 75% of all Achilles tendon ruptures occur during recreational activities. There is a trend towards a higher incidence of ruptures because of the increasing popularity of sport activities among “weekend warriors,” many of whom are 30 to 40 years of age.1 The current treatments can be classified as either nonoperative (casting or functional bracing) or operative,2 which includes open repair, percutaneous techniques, and endoscopically assisted percutaneous repair.3 Some authors advocate conservative treatment4,5 while others strongly recommend surgery.6-9 In general, operative management offers a lower rerupture rate, early functional treatment, less calf atrophy, and stronger push off.7,9,10 Nevertheless, it is
From the Second Orthopaedic Department, Panarcadian General Hospital, Tripolis, Greece. The authors report no conflict of interest. Address correspondence and reprint requests to Andreas A. Lamprakis, M.D., Ionias 2 St., Pefki, 151 21, Athens, Greece. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2406-7495$34.00/0 doi:10.1016/j.arthro.2008.02.018
associated with a significant number of wound complications.8,11-14 In 1977, Ma and Griffith15 described a technique of percutaneous repair, decreasing the complication rates of open surgery. This study was followed by several reports with similar results.13,16,17 However, this technique is regarded to place the sural nerve at danger, causes misalignment of the stumps, decreases the strength of the repaired site, and leads to a higher re-rupture rate.3,6,10 A meta-analysis of 12 trials involving 800 patients confirmed that open surgery results in a lower re-rupture rate but a higher risk of overall complications when compared to conservative treatment. The same study showed that percutaneous repair and the use of a functional brace postoperatively were associated with a lower complication rate.9 According to Goren et al.,18 the biomechanical outcomes of open surgery and percutaneous repair are both effective in functional terms. Treatment results are determined not only by the method of repair but also by the early postoperative functional rehabilitation.19 The best option should not rely solely on the re-rupture and wound complication
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 6 (June), 2008: pp 683-688
683
684
A. P. FORTIS ET AL.
rate but also on the utility that the patient has for these outcomes.11 In general, the studies reporting Achilles tendon rupture and mode of management are increasing, while the complication rates are decreasing.7 An endoscopically assisted percutaneous repair seems to overcome certain problems of previous techniques.20 Direct visualization of the rupture site using an endoscope increases repair precision and minimizes wound complications. The aim of the present study was to evaluate the results of endoscopically assisted percutaneous repair of Achilles tendon rupture. Our hypothesis was that the technique would prove to be safe, with both good outcomes and minimal complications. METHODS This prospective study was conducted at a level I trauma center. Twenty patients (18 males and 2 females) 28 to 47 years of age (mean, 36.75 years) underwent operations to repair an Achilles tendon rupture between 1998 and 2003. There were 10 rightsided and 10 left-sided ruptures (Table 1). All except 1 were amateur athletes, and 2 had sustained the rupture 3 weeks before examination. Patients with re-rupture, open rupture, previous Achilles tendinopathy, previous local steroid injection, systemic corticosteroid treatment, diabetes mellitus, and autoimmune diseases were excluded. Study inclusion criteria were limited to patients younger than 60 years, compliant to TABLE 1.
surgical and postoperative cast treatment. The mechanisms of trauma included sports-related activites (soccer, basketball, jogging, tennis, volleyball, and aerobics), fall from a height, and missing a stair in a staircase. Diagnosis was based on clinical examination, existence of a palpable gap in the area of rupture, and a positive Thompson’s test result. All patients were operated upon by the same orthopedic consultant. Under general anesthesia and using a tourniquet, the patient was placed in the prone position. After marking the site of the gap on the skin, one arthroscopic portal of entry was made medially and another dorsolaterally to the rupture site. Two accessory working accesses were made on the dorsal surface of the tendon, one proximally and one distally to the gap. Thirty-degree and 0° scopes were used. Under continuous irrigation using a pump, the paratenon and the rupture ends (Fig 1) were identified. The suture was passed through needles under endoscopic control to ensure passing through the lips of both ends. After tightening the first suture, a remaining gap was inspected under direct visualization, especially in the ventral and lateral parts (Figs 2 and 3). Additional sutures were performed until the torn ends were satisfactorily closed and aligned (Fig 4). To avoid sural nerve entrapment, no sutures in the ventral portion were placed. The knots were buried underneath the skin and all remaining wounds were left open. No drainage was used.
Demographic Data and Merkel Score Results on Achilles Rupture Patients
Gender
Age (y)
Side
Height (cm)
Weight (kg)
Trauma
Complications
Modified Merkel Scale
M M M M F M F M M M M M M M M M M M M M
32 32 46 44 32 35 36 46 37 47 29 39 43 33 35 39 28 41 28 33
L R R L R L L L R R L R L L R L R L R R
192 184 165 180 170 182 178 173 176 185 182 179 182 163 170 175 173 183 178 186
115 78 85 92 76 98 70 76 84 85 80 75 80 68 74 80 76 87 85 87
Basketball Soccer Stairs Fall Aerobics Soccer Tennis Soccer Basketball Soccer Jogging Soccer Soccer Jogging Soccer Basketball Tennis Soccer Soccer Volleyball
– Sural neuralgia – – – – – – – – – – Sural neuralgia – – – – – – –
641 547 576 577 662 631 621 562 641 655 581 641 571 566 641 631 579 618 557 582
ACHILLES TENDON RUPTURE UNDER ENDOSCOPY
FIGURE 1. Inspection of the torn ends and initial gap under arthroscopy.
Postoperatively, all patients were mobilized with partial to full weight bearing in a below-knee walking plaster cast in the gravity equinus position for 2 weeks. Afterwards, the plaster cast was exchanged to a removable, full weight bearing back slab and active ankle mobilization was begun for 1 month. After cast removal at 6 weeks postoperatively, each patient wore an insole wedge pad underneath the heel for 3 months. Follow-up appointments were arranged for all patients at 2, 6, and 12 weeks and at every 6 months until completion of 2 and a half years of postoperative follow-up. Evaluation entailed the heel raise test21 and a modified Merkel’s scale.22 The heel raise test was performed using a digital counter (Digitaker 90003001; Iteco, Giaveno, Italy) and included the number of
FIGURE 2. Endoscopic view of the remaining gap after the first suture. Additional sutures are needed for full approximation.
FIGURE 3.
685
Remaining gap and knot inspection.
standing unilateral heel raises more than 5 cm from the ground until a patient was fatigued. For statistical analysis, a random effects Poisson regression model was used. Merkel’s scoring system included evaluation of pain (maximum points, 300) and functional load weight bearing capacity (maximum points, 400), with a maximum total score of 700 points. RESULTS Table 1 shows the results from the modified Merkel scale for each patient. A median score of 600 points and mean score of 604 were achieved. Seventy percent of patients had no pain at rest, while 30% had mild pain from time to time, but with no limitations in daily activities. No patients suffered from intense
FIGURE 4. Anatomic apposition and gap obliteration of the rupture site after repair.
686
A. P. FORTIS ET AL.
pain, pain on weight bearing, or at the end of maximal dorsal or plantar flexion. All could walk 1 to 5 km over uneven ground pain-free, and all were able to stand on the tiptoe of the operated leg. Continuous standing for almost 30 seconds on both toes and on toes of the ruptured side was achieved in 80% and 65%, respectively. On average, the number of heel raises was 29 for the injured side and 33 for the uninjured side. A 12% decrease in maximum torque and 16.5% decrease in work performance of the operated side were reported. Lower scores were noted in the patients with long-standing rupture and sural nerve damage. According to the results of the heel raise test, the number of raises of more than 5 cm appeared lower in the right, while there was no difference in the left leg. In order to identify statistically significant differences in the number of raises of more than 5 cm, a random effects Poisson regression model was fitted. An interaction term, initially included, was not significant (P ⫽ .321) and therefore was excluded from the final model. The number of raises over leg (left/right) and operation status (yes/no) was regressed. Differences by leg were not significant (P ⫽ .356). Although the mean estimated number of raises of more than 5 cm was 9.9% lower for the operated legs, this difference was not significant at a 5% confidence level (P ⫽ .065; Table 2). No patient had a deep infection, wound healing problems, or re-rupture. One patient experienced sural neuralgia that subsided with no further treatment within 5 months. One patient reported a persistent “funny feeling” in the lateral surface of his little toe when a sheet was rubbed on it, and still has some numbness in a small area around the lateral lip of the foot. Both patients with a long-standing rupture of 3 weeks’ duration underwent magnetic resonance imaging examination 2 years postoperatively; no problems were found in either of the repaired sites. However, ultrasonography and magnetic resonance imaging have a limited role to play during the healing process after Achilles tendon rupture because of their weak correlation with clinical findings.23
TABLE 2.
Differences in No. of Raises More Than 5 cm Between Groups Mean Estimated Relative Differences (%)
Leg Operated v non-operated Left v right
Percent Difference (95% CI) ⫺9.9 (⫺19.4 to 0.7) ⫺5.1 (⫺15.1 to 6.1)
P .065 .356
All patients were back to their previous activity levels at the 2 and a half year follow-up, and all stated that under the same circumstances, they would again have the operation. DISCUSSION There is still controversy over the optimal management of Achilles tendon rupture. In active, young, very demanding individuals, surgical repair should be considered, while conservative treatment should be reserved for elderly or sedentary patients.2,7 Open surgery needs longer tendon exposure and results in damage to its blood supply and gliding structures. It predisposes to adhesion formation, impairing the final outcome. A variety of percutaneous techniques have been described with a low rate of complications.24-26 The combined mini-open and percutaneous repair gives similar or even better results than the other surgical procedures.27,28 Nevertheless, even a miniincision can have the disadvantages of an open repair, as far as wound complications are concerned. Simple “blind” percutaneous repair does not allow for perfect adaptation of the tendon stumps and therefore has a higher re-rupture rate.6,10,25 Intraoperative sonography during percutaneous treatment may assure good apposition of tendon ends and improve postoperative rehabilitation.29 Nevertheless, a gap can be better visualized under endoscopic control, and the repair can be further strengthened with additional sutures. A remaining gap was also observed after the initial suture in some of our cases, which required further sutures to minimize. Sural nerve entrapment is a serious complication following percutaneous repair, reaching a prevalence of 18%,30 and impairing functional outcome.31 However, nerve impairment may often be caused by traumatic stretching and neuropraxia.26 Using posterior incisions, local anesthesia,13 and placement of surgical knots at the medial aspect of the Achilles tendon25 have been described in order to avoid sural nerve injury. According to Majewski et al.,30 the careful placement of incisions to expose the sural nerve can reduce the incidence of its entrapment. An endoscopically assisted percutaneous technique was described by Thermann et al.32 in order to prevent sural nerve injury. In the present study, sural neuralgia was 10% but transient in 1 case, which subsided. Avoiding the tendon’s lateral aspect could minimize the chance of injury. It is our preference to draw a line dividing the tendon area into one third laterally and two thirds medially. Applying the sutures laterally to this line
ACHILLES TENDON RUPTURE UNDER ENDOSCOPY can endanger the nerve; in fact, in each of the 2 patients with sural neuralgia, 1 of the sutures had been placed beyond this line. Although many different scoring systems exist in order to assess the clinical outcome of Achilles tendon repair, there is no universally accepted one, because of subjective parameters and technical or financial reasons. Therefore, it is difficult to interpret and compare the outcome results of different techniques. Goren et al.18 showed that percutaneous treatment results in an average loss of strength of 16% in the injured side, while open repair results in an 18.2% loss of strength. Endurance evaluation revealed a 28% decrease in total work measurements in the injured side treated percutaneously and a 26.6% treated by open repair. However, no statistically significant differences for the above parameters were observed between types of repair, which is in agreement with other studies.13,16 Functional results of operative and conservative treatment were equivalent according to Weber et al.5 A modified Therman score was used, and the conservatively managed group achieved a score of 85 of 100, while the surgically treated group achieved a score of 84 of 100. Repetitive heel raises of the injured leg reached 85% of healthy side in the conservative group and 83% in the operative side.5 A functional comparison of 3 surgical techniques by Rebeccato et al.28 revealed a 26% loss of strength of the injured part in patients with open repair, a 12% in those with percutaneous repair, and 8% with combined mini-open and percutaneous procedures. Forty percent of patients with open repair were not able to perform 20 toeraises on each side.28 A modified Merkel scale was used by Kosanovic and Brilej33 in order to evaluate percutaneous repair of chronic ruptures. Results were good to excellent in 95% of patients, with an average of 13 heel raises on the injured side. The difference in work performance between sides was 29%, and the power of plantar flexion reached a mean of 87.5% of the normal leg. Seventy-eight percent of patients returned to previous level of activity.33 Satisfactory results have been obtained by other studies using arthroscopically assisted percutaneous repair.20,34,35 In a cadaveric and clinical study by Turgut et al.,20 all patients had good results without any complications. Although anatomic apposition of the tendon ends was achieved, attempts to visualize the sural nerve failed. The difference in range of motion of the ankle joint and calf circumference between the sides was not significant; all patients could walk and stand on tiptoe.20 According to Halasi et al.,34 Achilles tendoscopy offered a more precise repair, controlling
687
the adaptation of the tendon ends. The re-rupture rate was lower, but not significant when compared to simple percutaneous repair. One partial re-rupture, 1 deep vein thrombosis, and 4 cases with fusiform thickening (indicating delayed healing) were reported. Results were excellent in 65% and good in 24% of patients, according to the opinions of the patients. The mean plantar flexion strength compared with the non-affected side was 86%, the sports activity level decreased in 24%, and 16% of patients gave up on sports.34 Good clinical results and accelerated functional recovery were achieved by patients in a study by Tang et al.,35 who performed percutaneous Kessler’s suture under arthroscopy and immobilization of the leg with a long splint for 6 weeks. According to the Arner and Lindholm scale used, excellent results were achieved in 75% and good in 25% of patients. A lower score was noted in patients with slightly hampered walking, limited mobility of the talocrural joint, and decreased calf circumference.35 Lui3 described 2 modifications in order to enhance the strength of repair and minimize sural nerve injury: the investing fascia at the medial border of the tendon is released, Krackow interlocking sutures at the tendon ends are placed, and the repair is augmented with plantaris tendon graft. Our 2 and a half year follow-up showed no wound complications and no re-ruptures, but did show a 10% occurrence rate of sural neuralgia. Full approximation of the tendon ends under endoscopic control and our postoperative rehabilitation program resulted in good functional outcomes, as measured by both the Merkel scale and the heel raise test. All patients were able to return to previous activity level and remained satisfied with their treatment results. All could stand on the toes of the injured leg and walk without a marked limp. The heel raise test for endurance showed a 10% decrease of the mean estimated number of raises on the injured side. However, this difference was not significant. A 12% difference in maximum torque and 16.5% decrease in work performance between sides were noted. Although this deficit did not limit the activities of our group of patients, it is possible to have had a different impact in a population of professional athletes. Our findings show that the functional outcomes of endoscopic repair are as successful as those of open and percutaneous techniques. The weaknesses of the present study include the small number of patients and the study not being controlled or randomized. The endoscopic approach requires a relatively steep learning curve, the use of arthroscopic equipment, and outcomes from larger prospective studies. However, this technique seems to overcome previous
688
A. P. FORTIS ET AL.
problems of conservative, open, and percutaneous repair. It is a safe method, aiming to control the adaptation of the tendon ends and to decrease sural nerve damage. It offers good wound healing, minimizing adhesion formation to the scar, and protects peritenon blood supply. CONCLUSIONS Percutaneous Achilles tendon repair under arthroscopic control is a reasonable alternative, with direct visualization during suturing, gap inspection, and reinforcement of the repaired site when necessary. Our approach results in minimal wound complications, early mobilization, and good functional recovery. Although it is a safe and promising technique, sural neuralgia and some decrease in maximum torque and work performance remain potential problems. REFERENCES 1. Suchak A, Bostick G, Reid D, Blitz S, Jomha N. The incidence of Achilles tendon ruptures in Edmonton, Canada. Foot Ankle Int 2005;26:932-936. 2. Sauer ST, Marymont JV, Mizel MS. What’s new in foot and ankle surgery. J Bone Joint Surg Am 2004;86:878-886. 3. Lui TH. Endoscopic-assisted Achilles tendon repair with plantaris tendon augmentation. Arthroscopy 2007;23:556.e1-556.e5. 4. Ingvar J, Tagil M, Eneroth M. Nonoperative treatment of Achilles tendon rupture: 196 consecutive patients with a 7% re-rupture rate. Acta Orthop 2005;76:597-601. 5. Weber M, Niemann M, Lanz R, Muller T. Nonoperative treatment of acute rupture of the Achilles tendon: Results of a new protocol and comparison with operative treatment. Am J Sports Med 2003;31:685-691. 6. Maffulli N. Current concepts review—Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036. 7. Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J Sports Med 2002;30:565-575. 8. Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med 1998;25:79-100. 9. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures. A metaanalysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87:2202-2210. 10. Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendo Achillis: A prospective, randomized study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 2001;83:843-848. 11. Kocher MS, Bishop J, Marshall R, Briggs KK, Hawkins R. Operative versus nonoperative management of acute Achilles tendon rupture. Am J Sports Med 2002;30:783-788. 12. Strauss E, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: An institutional review of clinical outcomes. Injury 2007;38:832-838. 13. Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: A comparative study. Am J Sports Med 2005;33:1369-1379. 14. Li J, Xu Y, Wang X. Management of soft tissue defect after Achilles tendon repair. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2007;21:367-370.
15. Ma GWC, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: A new technique. Clin Orthop Relat Res 1977;128:247-255. 16. Gigante A, Moschini A, Verdenelli A, Del Torto M, Ulisse S, de Palma L. Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: A randomized prospective study. Knee Surg Sports Traumatol Arthrosc 2008;16:204-209. 17. Haji A, Sahai A, Symes A, Vyas JK. Percutaneous versus open tendo Achillis repair. Foot Ankle Int 2004;25:215-218. 18. Goren D, Ayalon M, Nyska M. Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles tendon ruptures. Foot Ankle Int 2005;26:286-290. 19. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: A randomized comparison of 2 postoperative regimens. Am J Sports Med 2007;35:59-64. 20. Turgut A, Gunal I, Maralcan G, Kose N, Gokturk E. Endoscopy, assisted percutaneous repair of the Achilles tendon ruptures: A cadaveric and clinical study. Knee Surg Sports Traumatol Arthrosc 2002;10:130-133. 21. Moller M, Lind K, Styf J, Karlsson J. The reliability of isokinetic testing of the ankle joint and a heel-raise test for endurance. Knee Surg Sports Traumatol Arthrosc 2005;13:60-71. 22. Merkel M, Neumann HW, Merk H. A new score for comparing outcome of surgical management of Achilles tendon ruptures. Chirurg 1996;67:1141-1146. 23. Moller M, Kalebo P, Tidebrant G, Movin T, Karlsson J. The ultrasonographic appearance of the ruptured Achilles tendon during healing: A longitudinal evaluation of surgical and nonsurgical treatment, with comparisons to MRI appearance. Knee Surg Sports Traumatol Arthrosc 2001;10:49-56. 24. Carmont M, Maffulli N. Modified percutaneous repair of ruptured Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2008;16:199-203. 25. Wagnon R, Akayi M. The Webb-Bannister percutaneous technique for acute Achilles’ tendon ruptures: A functional and MRI assessment. J Foot Ankle Surg 2005;44:437-444. 26. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon—A prospective randomized controlled study. Foot Ankle Int 2001;22:559-568. 27. Ceccarelli F, Berti L, Giuriati L, Romagnoli M, Giannini S. Percutaneous and minimally invasive techniques of Achilles tendon repair. Clin Orthop Relat Res 2007;458:188-193. 28. Rebeccato A, Santini S, Salmaco G, Nogarin L. Repair of the Achilles tendon rupture: A functional comparison of three surgical techniques. J Foot Ankle Surg 2001;40:188-194. 29. Blankstein A, Israeli A, Dudkiewicz I, Chechik A, Ganel A. Percutaneous Achilles tendon repair combined with real-time sonography. Isr Med Assoc J 2007;9:83-85. 30. Majewski M, Rohrbach M, Czaja S, Ochsner P. Avoiding sural nerve injuries during percutaneous Achilles tendon repair. Am J Sports Med 2006;34:793-798. 31. Maes R, Copin G, Averous C. Is percutaneous repair of the Achilles tendon a safe technique? A study of 124 cases. Acta Orthop Belg 2006;72:179-183. 32. Thermann H, Tibesku C, Mastrokalos D, Passler H. Technique tip: Endoscopically assisted percutaneous Achilles tendon suture. Foot Ankle Int 2001;22:158-160. 33. Kosanovic M, Brilej D. Chronic rupture of Achilles tendon: Is the percutaneous suture technique effective? Arch Orthop Trauma Surg 2008;128:211-216. 34. Halasi T, Tallay A, Berkes I. Percutaneous Achilles tendon repair with and without endoscopic control. Knee Surg Sports Traumatol Arthrosc 2003;11:409-414. 35. Tang KL, Thermann H, Dai G, Chen GX, Guo L, Yang L. Arthroscopically assisted percutaneous repair of fresh closed Achilles tendon rupture by Kessler’s suture. Am J Sports Med 2007;35:589-596.
Purpose: To evaluate the functional outcomes and complications after endoscopically assisted percutaneous repair of Achilles tendon rupture. Methods: An arthroscopically assisted percutaneous repair was performed in 20 patients between the ages of 28 and 47 years. Two patients were suffering from a long-standing rupture. Follow-up was 2.5 years. Evaluation entailed Merkel’s scale for pain, functional load (weight) bearing capacity, and the heel raise test. For statistical analysis, a random effects Poisson regression model was used. Results: All patients achieved good to excellent outcomes. The median score on Merkel’s scale was 600. All patients were able to stand on the tiptoe of the operated leg and none had limitations placed on their daily activities. A 12% decrease in maximum torque and 16.5% decrease in work performance of the injured side were noted. There was no statistical significant difference in the heel raise test between the operated and non-operated leg. No wound problems, re-ruptures, or infections were reported. Two patients (10%) had sural neuralgia; in 1 case, it subsided without further treatment. Conclusions: Endoscopy in percutaneous Achilles tendon repair is useful in determining the initial gap and providing adequate apposition of the tendon ends. It is a safe technique with good outcomes and minimal complications. Despite its promising results, potential problems include sural neuralgia and some decrease in strength. Level of Evidence: Level IV, therapeutic case series. Key Words: Achilles tendon rupture—Endoscopy— Percutaneous repair.
A
pproximately 75% of all Achilles tendon ruptures occur during recreational activities. There is a trend towards a higher incidence of ruptures because of the increasing popularity of sport activities among “weekend warriors,” many of whom are 30 to 40 years of age.1 The current treatments can be classified as either nonoperative (casting or functional bracing) or operative,2 which includes open repair, percutaneous techniques, and endoscopically assisted percutaneous repair.3 Some authors advocate conservative treatment4,5 while others strongly recommend surgery.6-9 In general, operative management offers a lower rerupture rate, early functional treatment, less calf atrophy, and stronger push off.7,9,10 Nevertheless, it is
From the Second Orthopaedic Department, Panarcadian General Hospital, Tripolis, Greece. The authors report no conflict of interest. Address correspondence and reprint requests to Andreas A. Lamprakis, M.D., Ionias 2 St., Pefki, 151 21, Athens, Greece. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2406-7495$34.00/0 doi:10.1016/j.arthro.2008.02.018
associated with a significant number of wound complications.8,11-14 In 1977, Ma and Griffith15 described a technique of percutaneous repair, decreasing the complication rates of open surgery. This study was followed by several reports with similar results.13,16,17 However, this technique is regarded to place the sural nerve at danger, causes misalignment of the stumps, decreases the strength of the repaired site, and leads to a higher re-rupture rate.3,6,10 A meta-analysis of 12 trials involving 800 patients confirmed that open surgery results in a lower re-rupture rate but a higher risk of overall complications when compared to conservative treatment. The same study showed that percutaneous repair and the use of a functional brace postoperatively were associated with a lower complication rate.9 According to Goren et al.,18 the biomechanical outcomes of open surgery and percutaneous repair are both effective in functional terms. Treatment results are determined not only by the method of repair but also by the early postoperative functional rehabilitation.19 The best option should not rely solely on the re-rupture and wound complication
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 6 (June), 2008: pp 683-688
683
684
A. P. FORTIS ET AL.
rate but also on the utility that the patient has for these outcomes.11 In general, the studies reporting Achilles tendon rupture and mode of management are increasing, while the complication rates are decreasing.7 An endoscopically assisted percutaneous repair seems to overcome certain problems of previous techniques.20 Direct visualization of the rupture site using an endoscope increases repair precision and minimizes wound complications. The aim of the present study was to evaluate the results of endoscopically assisted percutaneous repair of Achilles tendon rupture. Our hypothesis was that the technique would prove to be safe, with both good outcomes and minimal complications. METHODS This prospective study was conducted at a level I trauma center. Twenty patients (18 males and 2 females) 28 to 47 years of age (mean, 36.75 years) underwent operations to repair an Achilles tendon rupture between 1998 and 2003. There were 10 rightsided and 10 left-sided ruptures (Table 1). All except 1 were amateur athletes, and 2 had sustained the rupture 3 weeks before examination. Patients with re-rupture, open rupture, previous Achilles tendinopathy, previous local steroid injection, systemic corticosteroid treatment, diabetes mellitus, and autoimmune diseases were excluded. Study inclusion criteria were limited to patients younger than 60 years, compliant to TABLE 1.
surgical and postoperative cast treatment. The mechanisms of trauma included sports-related activites (soccer, basketball, jogging, tennis, volleyball, and aerobics), fall from a height, and missing a stair in a staircase. Diagnosis was based on clinical examination, existence of a palpable gap in the area of rupture, and a positive Thompson’s test result. All patients were operated upon by the same orthopedic consultant. Under general anesthesia and using a tourniquet, the patient was placed in the prone position. After marking the site of the gap on the skin, one arthroscopic portal of entry was made medially and another dorsolaterally to the rupture site. Two accessory working accesses were made on the dorsal surface of the tendon, one proximally and one distally to the gap. Thirty-degree and 0° scopes were used. Under continuous irrigation using a pump, the paratenon and the rupture ends (Fig 1) were identified. The suture was passed through needles under endoscopic control to ensure passing through the lips of both ends. After tightening the first suture, a remaining gap was inspected under direct visualization, especially in the ventral and lateral parts (Figs 2 and 3). Additional sutures were performed until the torn ends were satisfactorily closed and aligned (Fig 4). To avoid sural nerve entrapment, no sutures in the ventral portion were placed. The knots were buried underneath the skin and all remaining wounds were left open. No drainage was used.
Demographic Data and Merkel Score Results on Achilles Rupture Patients
Gender
Age (y)
Side
Height (cm)
Weight (kg)
Trauma
Complications
Modified Merkel Scale
M M M M F M F M M M M M M M M M M M M M
32 32 46 44 32 35 36 46 37 47 29 39 43 33 35 39 28 41 28 33
L R R L R L L L R R L R L L R L R L R R
192 184 165 180 170 182 178 173 176 185 182 179 182 163 170 175 173 183 178 186
115 78 85 92 76 98 70 76 84 85 80 75 80 68 74 80 76 87 85 87
Basketball Soccer Stairs Fall Aerobics Soccer Tennis Soccer Basketball Soccer Jogging Soccer Soccer Jogging Soccer Basketball Tennis Soccer Soccer Volleyball
– Sural neuralgia – – – – – – – – – – Sural neuralgia – – – – – – –
641 547 576 577 662 631 621 562 641 655 581 641 571 566 641 631 579 618 557 582
ACHILLES TENDON RUPTURE UNDER ENDOSCOPY
FIGURE 1. Inspection of the torn ends and initial gap under arthroscopy.
Postoperatively, all patients were mobilized with partial to full weight bearing in a below-knee walking plaster cast in the gravity equinus position for 2 weeks. Afterwards, the plaster cast was exchanged to a removable, full weight bearing back slab and active ankle mobilization was begun for 1 month. After cast removal at 6 weeks postoperatively, each patient wore an insole wedge pad underneath the heel for 3 months. Follow-up appointments were arranged for all patients at 2, 6, and 12 weeks and at every 6 months until completion of 2 and a half years of postoperative follow-up. Evaluation entailed the heel raise test21 and a modified Merkel’s scale.22 The heel raise test was performed using a digital counter (Digitaker 90003001; Iteco, Giaveno, Italy) and included the number of
FIGURE 2. Endoscopic view of the remaining gap after the first suture. Additional sutures are needed for full approximation.
FIGURE 3.
685
Remaining gap and knot inspection.
standing unilateral heel raises more than 5 cm from the ground until a patient was fatigued. For statistical analysis, a random effects Poisson regression model was used. Merkel’s scoring system included evaluation of pain (maximum points, 300) and functional load weight bearing capacity (maximum points, 400), with a maximum total score of 700 points. RESULTS Table 1 shows the results from the modified Merkel scale for each patient. A median score of 600 points and mean score of 604 were achieved. Seventy percent of patients had no pain at rest, while 30% had mild pain from time to time, but with no limitations in daily activities. No patients suffered from intense
FIGURE 4. Anatomic apposition and gap obliteration of the rupture site after repair.
686
A. P. FORTIS ET AL.
pain, pain on weight bearing, or at the end of maximal dorsal or plantar flexion. All could walk 1 to 5 km over uneven ground pain-free, and all were able to stand on the tiptoe of the operated leg. Continuous standing for almost 30 seconds on both toes and on toes of the ruptured side was achieved in 80% and 65%, respectively. On average, the number of heel raises was 29 for the injured side and 33 for the uninjured side. A 12% decrease in maximum torque and 16.5% decrease in work performance of the operated side were reported. Lower scores were noted in the patients with long-standing rupture and sural nerve damage. According to the results of the heel raise test, the number of raises of more than 5 cm appeared lower in the right, while there was no difference in the left leg. In order to identify statistically significant differences in the number of raises of more than 5 cm, a random effects Poisson regression model was fitted. An interaction term, initially included, was not significant (P ⫽ .321) and therefore was excluded from the final model. The number of raises over leg (left/right) and operation status (yes/no) was regressed. Differences by leg were not significant (P ⫽ .356). Although the mean estimated number of raises of more than 5 cm was 9.9% lower for the operated legs, this difference was not significant at a 5% confidence level (P ⫽ .065; Table 2). No patient had a deep infection, wound healing problems, or re-rupture. One patient experienced sural neuralgia that subsided with no further treatment within 5 months. One patient reported a persistent “funny feeling” in the lateral surface of his little toe when a sheet was rubbed on it, and still has some numbness in a small area around the lateral lip of the foot. Both patients with a long-standing rupture of 3 weeks’ duration underwent magnetic resonance imaging examination 2 years postoperatively; no problems were found in either of the repaired sites. However, ultrasonography and magnetic resonance imaging have a limited role to play during the healing process after Achilles tendon rupture because of their weak correlation with clinical findings.23
TABLE 2.
Differences in No. of Raises More Than 5 cm Between Groups Mean Estimated Relative Differences (%)
Leg Operated v non-operated Left v right
Percent Difference (95% CI) ⫺9.9 (⫺19.4 to 0.7) ⫺5.1 (⫺15.1 to 6.1)
P .065 .356
All patients were back to their previous activity levels at the 2 and a half year follow-up, and all stated that under the same circumstances, they would again have the operation. DISCUSSION There is still controversy over the optimal management of Achilles tendon rupture. In active, young, very demanding individuals, surgical repair should be considered, while conservative treatment should be reserved for elderly or sedentary patients.2,7 Open surgery needs longer tendon exposure and results in damage to its blood supply and gliding structures. It predisposes to adhesion formation, impairing the final outcome. A variety of percutaneous techniques have been described with a low rate of complications.24-26 The combined mini-open and percutaneous repair gives similar or even better results than the other surgical procedures.27,28 Nevertheless, even a miniincision can have the disadvantages of an open repair, as far as wound complications are concerned. Simple “blind” percutaneous repair does not allow for perfect adaptation of the tendon stumps and therefore has a higher re-rupture rate.6,10,25 Intraoperative sonography during percutaneous treatment may assure good apposition of tendon ends and improve postoperative rehabilitation.29 Nevertheless, a gap can be better visualized under endoscopic control, and the repair can be further strengthened with additional sutures. A remaining gap was also observed after the initial suture in some of our cases, which required further sutures to minimize. Sural nerve entrapment is a serious complication following percutaneous repair, reaching a prevalence of 18%,30 and impairing functional outcome.31 However, nerve impairment may often be caused by traumatic stretching and neuropraxia.26 Using posterior incisions, local anesthesia,13 and placement of surgical knots at the medial aspect of the Achilles tendon25 have been described in order to avoid sural nerve injury. According to Majewski et al.,30 the careful placement of incisions to expose the sural nerve can reduce the incidence of its entrapment. An endoscopically assisted percutaneous technique was described by Thermann et al.32 in order to prevent sural nerve injury. In the present study, sural neuralgia was 10% but transient in 1 case, which subsided. Avoiding the tendon’s lateral aspect could minimize the chance of injury. It is our preference to draw a line dividing the tendon area into one third laterally and two thirds medially. Applying the sutures laterally to this line
ACHILLES TENDON RUPTURE UNDER ENDOSCOPY can endanger the nerve; in fact, in each of the 2 patients with sural neuralgia, 1 of the sutures had been placed beyond this line. Although many different scoring systems exist in order to assess the clinical outcome of Achilles tendon repair, there is no universally accepted one, because of subjective parameters and technical or financial reasons. Therefore, it is difficult to interpret and compare the outcome results of different techniques. Goren et al.18 showed that percutaneous treatment results in an average loss of strength of 16% in the injured side, while open repair results in an 18.2% loss of strength. Endurance evaluation revealed a 28% decrease in total work measurements in the injured side treated percutaneously and a 26.6% treated by open repair. However, no statistically significant differences for the above parameters were observed between types of repair, which is in agreement with other studies.13,16 Functional results of operative and conservative treatment were equivalent according to Weber et al.5 A modified Therman score was used, and the conservatively managed group achieved a score of 85 of 100, while the surgically treated group achieved a score of 84 of 100. Repetitive heel raises of the injured leg reached 85% of healthy side in the conservative group and 83% in the operative side.5 A functional comparison of 3 surgical techniques by Rebeccato et al.28 revealed a 26% loss of strength of the injured part in patients with open repair, a 12% in those with percutaneous repair, and 8% with combined mini-open and percutaneous procedures. Forty percent of patients with open repair were not able to perform 20 toeraises on each side.28 A modified Merkel scale was used by Kosanovic and Brilej33 in order to evaluate percutaneous repair of chronic ruptures. Results were good to excellent in 95% of patients, with an average of 13 heel raises on the injured side. The difference in work performance between sides was 29%, and the power of plantar flexion reached a mean of 87.5% of the normal leg. Seventy-eight percent of patients returned to previous level of activity.33 Satisfactory results have been obtained by other studies using arthroscopically assisted percutaneous repair.20,34,35 In a cadaveric and clinical study by Turgut et al.,20 all patients had good results without any complications. Although anatomic apposition of the tendon ends was achieved, attempts to visualize the sural nerve failed. The difference in range of motion of the ankle joint and calf circumference between the sides was not significant; all patients could walk and stand on tiptoe.20 According to Halasi et al.,34 Achilles tendoscopy offered a more precise repair, controlling
687
the adaptation of the tendon ends. The re-rupture rate was lower, but not significant when compared to simple percutaneous repair. One partial re-rupture, 1 deep vein thrombosis, and 4 cases with fusiform thickening (indicating delayed healing) were reported. Results were excellent in 65% and good in 24% of patients, according to the opinions of the patients. The mean plantar flexion strength compared with the non-affected side was 86%, the sports activity level decreased in 24%, and 16% of patients gave up on sports.34 Good clinical results and accelerated functional recovery were achieved by patients in a study by Tang et al.,35 who performed percutaneous Kessler’s suture under arthroscopy and immobilization of the leg with a long splint for 6 weeks. According to the Arner and Lindholm scale used, excellent results were achieved in 75% and good in 25% of patients. A lower score was noted in patients with slightly hampered walking, limited mobility of the talocrural joint, and decreased calf circumference.35 Lui3 described 2 modifications in order to enhance the strength of repair and minimize sural nerve injury: the investing fascia at the medial border of the tendon is released, Krackow interlocking sutures at the tendon ends are placed, and the repair is augmented with plantaris tendon graft. Our 2 and a half year follow-up showed no wound complications and no re-ruptures, but did show a 10% occurrence rate of sural neuralgia. Full approximation of the tendon ends under endoscopic control and our postoperative rehabilitation program resulted in good functional outcomes, as measured by both the Merkel scale and the heel raise test. All patients were able to return to previous activity level and remained satisfied with their treatment results. All could stand on the toes of the injured leg and walk without a marked limp. The heel raise test for endurance showed a 10% decrease of the mean estimated number of raises on the injured side. However, this difference was not significant. A 12% difference in maximum torque and 16.5% decrease in work performance between sides were noted. Although this deficit did not limit the activities of our group of patients, it is possible to have had a different impact in a population of professional athletes. Our findings show that the functional outcomes of endoscopic repair are as successful as those of open and percutaneous techniques. The weaknesses of the present study include the small number of patients and the study not being controlled or randomized. The endoscopic approach requires a relatively steep learning curve, the use of arthroscopic equipment, and outcomes from larger prospective studies. However, this technique seems to overcome previous
688
A. P. FORTIS ET AL.
problems of conservative, open, and percutaneous repair. It is a safe method, aiming to control the adaptation of the tendon ends and to decrease sural nerve damage. It offers good wound healing, minimizing adhesion formation to the scar, and protects peritenon blood supply. CONCLUSIONS Percutaneous Achilles tendon repair under arthroscopic control is a reasonable alternative, with direct visualization during suturing, gap inspection, and reinforcement of the repaired site when necessary. Our approach results in minimal wound complications, early mobilization, and good functional recovery. Although it is a safe and promising technique, sural neuralgia and some decrease in maximum torque and work performance remain potential problems. REFERENCES 1. Suchak A, Bostick G, Reid D, Blitz S, Jomha N. The incidence of Achilles tendon ruptures in Edmonton, Canada. Foot Ankle Int 2005;26:932-936. 2. Sauer ST, Marymont JV, Mizel MS. What’s new in foot and ankle surgery. J Bone Joint Surg Am 2004;86:878-886. 3. Lui TH. Endoscopic-assisted Achilles tendon repair with plantaris tendon augmentation. Arthroscopy 2007;23:556.e1-556.e5. 4. Ingvar J, Tagil M, Eneroth M. Nonoperative treatment of Achilles tendon rupture: 196 consecutive patients with a 7% re-rupture rate. Acta Orthop 2005;76:597-601. 5. Weber M, Niemann M, Lanz R, Muller T. Nonoperative treatment of acute rupture of the Achilles tendon: Results of a new protocol and comparison with operative treatment. Am J Sports Med 2003;31:685-691. 6. Maffulli N. Current concepts review—Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036. 7. Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J Sports Med 2002;30:565-575. 8. Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med 1998;25:79-100. 9. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures. A metaanalysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87:2202-2210. 10. Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendo Achillis: A prospective, randomized study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 2001;83:843-848. 11. Kocher MS, Bishop J, Marshall R, Briggs KK, Hawkins R. Operative versus nonoperative management of acute Achilles tendon rupture. Am J Sports Med 2002;30:783-788. 12. Strauss E, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: An institutional review of clinical outcomes. Injury 2007;38:832-838. 13. Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: A comparative study. Am J Sports Med 2005;33:1369-1379. 14. Li J, Xu Y, Wang X. Management of soft tissue defect after Achilles tendon repair. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2007;21:367-370.
15. Ma GWC, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: A new technique. Clin Orthop Relat Res 1977;128:247-255. 16. Gigante A, Moschini A, Verdenelli A, Del Torto M, Ulisse S, de Palma L. Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: A randomized prospective study. Knee Surg Sports Traumatol Arthrosc 2008;16:204-209. 17. Haji A, Sahai A, Symes A, Vyas JK. Percutaneous versus open tendo Achillis repair. Foot Ankle Int 2004;25:215-218. 18. Goren D, Ayalon M, Nyska M. Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles tendon ruptures. Foot Ankle Int 2005;26:286-290. 19. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: A randomized comparison of 2 postoperative regimens. Am J Sports Med 2007;35:59-64. 20. Turgut A, Gunal I, Maralcan G, Kose N, Gokturk E. Endoscopy, assisted percutaneous repair of the Achilles tendon ruptures: A cadaveric and clinical study. Knee Surg Sports Traumatol Arthrosc 2002;10:130-133. 21. Moller M, Lind K, Styf J, Karlsson J. The reliability of isokinetic testing of the ankle joint and a heel-raise test for endurance. Knee Surg Sports Traumatol Arthrosc 2005;13:60-71. 22. Merkel M, Neumann HW, Merk H. A new score for comparing outcome of surgical management of Achilles tendon ruptures. Chirurg 1996;67:1141-1146. 23. Moller M, Kalebo P, Tidebrant G, Movin T, Karlsson J. The ultrasonographic appearance of the ruptured Achilles tendon during healing: A longitudinal evaluation of surgical and nonsurgical treatment, with comparisons to MRI appearance. Knee Surg Sports Traumatol Arthrosc 2001;10:49-56. 24. Carmont M, Maffulli N. Modified percutaneous repair of ruptured Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2008;16:199-203. 25. Wagnon R, Akayi M. The Webb-Bannister percutaneous technique for acute Achilles’ tendon ruptures: A functional and MRI assessment. J Foot Ankle Surg 2005;44:437-444. 26. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon—A prospective randomized controlled study. Foot Ankle Int 2001;22:559-568. 27. Ceccarelli F, Berti L, Giuriati L, Romagnoli M, Giannini S. Percutaneous and minimally invasive techniques of Achilles tendon repair. Clin Orthop Relat Res 2007;458:188-193. 28. Rebeccato A, Santini S, Salmaco G, Nogarin L. Repair of the Achilles tendon rupture: A functional comparison of three surgical techniques. J Foot Ankle Surg 2001;40:188-194. 29. Blankstein A, Israeli A, Dudkiewicz I, Chechik A, Ganel A. Percutaneous Achilles tendon repair combined with real-time sonography. Isr Med Assoc J 2007;9:83-85. 30. Majewski M, Rohrbach M, Czaja S, Ochsner P. Avoiding sural nerve injuries during percutaneous Achilles tendon repair. Am J Sports Med 2006;34:793-798. 31. Maes R, Copin G, Averous C. Is percutaneous repair of the Achilles tendon a safe technique? A study of 124 cases. Acta Orthop Belg 2006;72:179-183. 32. Thermann H, Tibesku C, Mastrokalos D, Passler H. Technique tip: Endoscopically assisted percutaneous Achilles tendon suture. Foot Ankle Int 2001;22:158-160. 33. Kosanovic M, Brilej D. Chronic rupture of Achilles tendon: Is the percutaneous suture technique effective? Arch Orthop Trauma Surg 2008;128:211-216. 34. Halasi T, Tallay A, Berkes I. Percutaneous Achilles tendon repair with and without endoscopic control. Knee Surg Sports Traumatol Arthrosc 2003;11:409-414. 35. Tang KL, Thermann H, Dai G, Chen GX, Guo L, Yang L. Arthroscopically assisted percutaneous repair of fresh closed Achilles tendon rupture by Kessler’s suture. Am J Sports Med 2007;35:589-596.