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Surgical repair of the Achilles tendon: the lateral approach
Original Article
Surgical repair of the Achilles tendon: the lateral approach A. P. Rumian, S. Molloy, M. Solan, K. J. Newman and D. Elliott
Introduction: Surgical repair of the Achilles tendon is associated with complications that are often wound related. Incisions in the midline or medial to the tendon pass through poorly vascularized tissue. A laterally placed incision passes through tissue with a rich vascular supply. Methods: A case-note analysis and telephone questionnaire was conducted for a consecutive series of 71 patients who had repair of their Achilles tendon via a lateral approach. Results: There was one case of superficial wound infection, one case of a sural nerve lesion, and two cases of reflex sympathetic dystrophy. There were no cases of deep wound infection, wound necrosis or tendon re-rupture. All patients were satisfied with scar cosmesis. Conclusion: The low rate of complications compared with that reported in other studies leads us to recommend the lateral approach for surgical repair of the Achilles tendon. ß 2001 Harcourt Publishers Ltd
Introduction
A.P. Rumian MA MBBS, S. Molloy MRCS, M. Solan FRCS, K.J. Newman FRCS (Orth), D. Elliott FRCS(Orth), Department of Orthopaedics, St Peter's Hospital, Chertsey, Surrey, UK
The incidence of Achilles tendon rupture is rising (Nillius et al. 1976, Leppilahti et al. 1996) but controversy still exists as to whether this injury should be treated operatively or non-operatively. Non- operative treatment is associated with an increased rate of tendon re-rupture (Maffulli 1999, Nistor 1981). Studies reporting the results of surgical repair of the Achilles tendon have shown a lower rate of re-rupture, but at the expense of surgical complications. These include wound infection, skin necrosis, tendon necrosis and scar tethering (Maffulli 1999). The most commonly used incisions for surgical repair are in the midline or medial to the tendon. These pass through poorly vascularized tissue (Maffulli 1099, Haertsch 1981) and this may explain the high incidence of wound complications. The vascular supply to the lateral side of the heel has formed the Basis of the lateral calcaneal skin ¯ap used in plastic surgery (Grabb & Argenta 1981, Hovius et al. 1988,
136 The Foot (2001) 11, 136±139
doi: 10.1054/foot.2001.0700, available online at http://www.idealibrary.com on
Schoen & Lease 1996, Borrelli & Lashgari 1999). The use of a laterally placed incision has been avoided for Achilles tendon repair because of the perceived risk of sural nerve damage. The course of the sural nerve has been extensively studied (deMoura & Gilbert 1984, Ortiguela et al. 1987, Eastwood et al. 1992). We have modi®ed the vertical limb of the extended lateral approach to the hindfoot described by Eastwood and Atkins (1992) in order to expose the Achilles tendon for operative repair. The aim of this paper is to report our experience of this lateral approach to the Achilles tendon.
Methods Seventy-one consecutive patients who underwent surgical repair of their Achilles tendon over a ®ve-year period were included in the study. All of the patients were under the care of two specialist trauma surgeons in the same District General Hospital. Demographic details, operative procedure, and postoperative management were
ß 2001 Harcourt Publishers Ltd
Surgical repair of the Achilles tendon
Fig. 1 Lateral approach to the achilles tendon with incision over the sural nerve.
recorded from the patient notes. A telephone questionnaire survey was conducted to identify all complications that may have occurred after discharge from follow-up clinic. Patients were also asked to grade the result of their surgery and to describe any limitations to their daily or recreational activities.
Surgical technique All repairs were carried out using the same technique with the patient positioned prone. The 6 cm incision starts approximately 7 cm proximal to the calcaneal insertion of the Achilles tendon. It lies midway between the lateral edge of the tendon and the posterior edge of the ®bula, directly over the sural nerve (Fig. 1). The sural nerve is identi®ed by blunt dissection in the proximal part of the incision (Fig. 2) and gently retracted laterally for protection. The incision can be extended further for either a high or low rupture. It must be remembered that the nerve becomes progressively more anterior as it courses distally.
ß 2001 Harcourt Publishers Ltd
Fig. 2 Sural nerve identified in the surgical field.
The posterior skin ¯ap is gently retracted posteriorly and the paratenon is opened from the lateral side to provide access to the Achilles tendon. In each case, the tendon was repaired using a modi®ed Kessler stitch with a looped absorbable mono®lament suture. Skin closure was achieved by a number of different methods but in the majority of cases a continuous absorbable subcuticular stitch was used. The paratenon was not closed separately because the edges come together as the skin is closed. A tourniquet was used for 65 of the cases (92%) with a mean tourniquet time of 32 min + 10.1 (range 18±74). Postoperatively, the foot was placed in equinus and held in a below-knee plaster-of-paris cast for two weeks. The cast was then changed and the equinus reduced. At four weeks, the patient was put in a below-knee weight-bearing plaster, with the foot at 908, for a further four weeks. This was followed by full mobilization and physiotherapy.
The Foot
(2001) 11, 136±139
137
Surgical repair of the Achilles tendon
Results All 71 patients in this study had repair of their Achilles tendon using the lateral approach. The mean age of the patients was 45 (range 26±68) and there were 46 men and 25 women. Thirty-seven patients had rupture of the right Achilles tendon and 34 the left. The mean length of follow-up was for 32 months (/ÿ 2.5 months). There were no cases of deep wound infection, wound necrosis, or tendon re-rupture. There was one case (1.4%) of a super®cial wound infection at the distal end of the incision. This resolved after a two-week course of oral antibiotics. There were two cases of re¯ex sympathetic dystrophy (2.8%). These resolved at 6 and 10 months respectively. One patient experienced persistent paraesthesia on the lateral border of the foot (1.4%). A sural nerve lesion was con®rmed by nerve conduction studies but the patient declined exploration of the wound. Ninety-two per cent of patients stated that the result of surgery was excellent and 8% rated it as good. None felt that it was fair or poor. Sixty-six per cent denied any functional limitation and were back to pre-injury levels of activity. Eighteen per cent described themselves as being more cautious in their activities because of apprehension of rerupture, but with no physical limitation. Sixteen per cent had complaints including a feeling of stiffness in the ankle (6 patients), weakness in the calf (3 patients), and a slight limp (2 patients). Speci®c questions about the scar revealed that 90% of patients had no complaints and 10% had minor symptoms: mild tenderness (3 patients), lumpiness (3 patients) and itch (1 patient). All patients were satis®ed with scar cosmesis. No patients had problems with footwear.
Discussion Operative repair of Achilles tendon rupture is often recommended for younger active patients and for athletes. Advantages include a lower incidence of re-rupture (1±5%) compared with re-rupture rates of between 8 and 35% for non-operative treatment (Maffulli 1999, Quigley & Scheller 1980, Mellor & Patterson 2000). Reported complications of operative repair are super®cial and deep wound infections, ®stulae, skin or tendon necrosis, scar adhesions to the underlying tendon, and sural nerve damage (Cetti et al. 1993,
138 The Foot (2001) 11, 136±139
Gillies & Chalmers 1970, Kellam et al. 1985). Surgical complications are therefore mainly wound related. Wounds heal with fewer complications in well-vascularized areas. We feel that there is a decreased risk of injuring vascular and neurological structures on the lateral side of the hindfoot. This makes it theoretically attractive to use a lateral approach. A lateral approach to the Achilles tendon has been associated with high incidence of sural nerve damage (Nistor 1981, Carden et al. 1987, Soldatis et al. 1997). This causes loss of sensation on the lateral aspect of the foot, and may result in a painful neuroma. In one series of 44 patients, 7 out of 9 patients who had sural nerve damage had had a lateral incision (Nistor 1981). In contrast, use of the extended lateral incision for the repair of calcaneal fractures, as described by Freeman, resulted in 4 cases of sural nerve dysfunction out of a series of 150 patients, none of which was permanent (Freeman et al. 1998). In this study, the vertical limb of the extended lateral incision has been modi®ed in that the most proximal part lies just lateral to the Achilles tendon rather than directly over it. This eliminates the chance of adhesions between skin and tendon. Rather than re¯ecting the sural nerve in a skin ¯ap unseen, the sural nerve is actively identi®ed and protected. In this study, only one patient (1.4%) suffered sural nerve damage. The surgeon had documented in the notes that the sural nerve had been identi®ed and protected throughout the procedure. In retrospect, it was felt that the sural nerve had been caught by a suture. The patient declined re-exploration of her wound. This review of a consecutive series of patients has shown an extremely favourable rate of wound infection (1.4%) compared with that found in the literature, which varies from 1.5% to 21%. There were minor symptoms related to the scar in 10% of patients. There were no tendon re-ruptures. In view of the extremely low rate of surgical complications in this series, we recommend the use of the lateral approach, with formal identi®cation and protection of the sural nerve, for repair of the Achilles tendon. References Borrelli J Jr, Lashgari C 1999 Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma 13(2): 73±77
ß 2001 Harcourt Publishers Ltd
Surgical repair of the Achilles tendon
Carden D G, Noble J, Chalmers J et al 1987 Rupture of the calcaneal tendon. The early and late management. J Bone Joint Surg [Br] 69(3): 416±420 Cetti R, Christensen S E, Ejsted R et al 1993 Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 21(6): 791±799 de Moura W, Gilbert A. Surgical anatomy of the sural nerve. J Reconstr Microsurg 1984; 1(1): 31±39 Eastwood D M, Atkins R M 1992 Lateral approaches to the heel. A comparison of two incisions for the fixation of calcaneal fractures. The Foot 2: 143±147 Eastwood D M, Irgau I, Atkins R M 1992 The distal course of the sural nerve and its significance for incisions around the lateral hindfoot. Foot Ankle 13(4): 199±202 Freeman B J, Duff S, Allen P E et al 1998 The extended lateral approach to the hindfoot. Anatomical basis and surgical implications. J Bone Joint Surg Br 80(1): 139±142 Gillies H, Chalmers J 1970 The management of fresh ruptures of the tendo achillis. J Bone Joint Surg [Am] 52(2): 337±343 Grabb W C, Argenta L C 1981 The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser saphenous vein, and sural nerve skin flap). Plast Reconstr Surg 68(5): 723±730 Haertsch P A 1981 The blood supply to the skin of the leg: a post-mortem investigation. Br J Plast Surg 34(4): 470±477
ß 2001 Harcourt Publishers Ltd
Hovius S E, Hofman A, van der Meulen J C 1988 Experiences with the lateral calcaneal artery flap. Ann Plast Surg 21(6): 532±535 Kellam J F, Hunter G A, McElwain J P 1985 Review of the operative treatment of Achilles tendon rupture. Clin Orthop 201: 80±83 Leppilahti J, Puranen J, Orava S 1996 Incidence of Achilles tendon rupture. Acta Orthop Scand 67(3): 277±279 Maffulli N 1099 Rupture of the Achilles tendon. J Bone Joint Surg [Am] 81(7): 1019±1036 Mellor S J, Patterson M H 2000 Tendo Achillis rupture: surgical repair is a safe option. Injury 31(7): 489±491 Nillius S A, Nilsson B E, Westlin N E 1976 The incidence of Achilles tendon rupture. Acta Orthop Scand 47(1): 118±121 Nistor L 1981 Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study. J Bone Joint Surg [Am] 63(3): 394±399 Ortiguela M E, Wood M B, Cahill D R 1987 Anatomy of the sural nerve complex. J Hand Surg [Am] 12(6): 1119±1123 Quigley T B, Scheller A D 1980 Surgical repair of the ruptured Achilles tendon. Analysis of 40 patients treated by the same surgeon. Am J Sports Med 8(4): 244±250 Schoen N S, Lease J. Lateral calcaneal artery flap for coverage of a posterior heel defect in a child. J Foot Ankle Surg 1996; 35(6): 567±572 Soldatis J J, Goodfellow D B, Wilber J H 1997 End-to-end operative repair of Achilles tendon rupture. Am J Sports Med 25(1): 90±95
The Foot
(2001) 11, 136±139
139
Surgical repair of the Achilles tendon: the lateral approach A. P. Rumian, S. Molloy, M. Solan, K. J. Newman and D. Elliott
Introduction: Surgical repair of the Achilles tendon is associated with complications that are often wound related. Incisions in the midline or medial to the tendon pass through poorly vascularized tissue. A laterally placed incision passes through tissue with a rich vascular supply. Methods: A case-note analysis and telephone questionnaire was conducted for a consecutive series of 71 patients who had repair of their Achilles tendon via a lateral approach. Results: There was one case of superficial wound infection, one case of a sural nerve lesion, and two cases of reflex sympathetic dystrophy. There were no cases of deep wound infection, wound necrosis or tendon re-rupture. All patients were satisfied with scar cosmesis. Conclusion: The low rate of complications compared with that reported in other studies leads us to recommend the lateral approach for surgical repair of the Achilles tendon. ß 2001 Harcourt Publishers Ltd
Introduction
A.P. Rumian MA MBBS, S. Molloy MRCS, M. Solan FRCS, K.J. Newman FRCS (Orth), D. Elliott FRCS(Orth), Department of Orthopaedics, St Peter's Hospital, Chertsey, Surrey, UK
The incidence of Achilles tendon rupture is rising (Nillius et al. 1976, Leppilahti et al. 1996) but controversy still exists as to whether this injury should be treated operatively or non-operatively. Non- operative treatment is associated with an increased rate of tendon re-rupture (Maffulli 1999, Nistor 1981). Studies reporting the results of surgical repair of the Achilles tendon have shown a lower rate of re-rupture, but at the expense of surgical complications. These include wound infection, skin necrosis, tendon necrosis and scar tethering (Maffulli 1999). The most commonly used incisions for surgical repair are in the midline or medial to the tendon. These pass through poorly vascularized tissue (Maffulli 1099, Haertsch 1981) and this may explain the high incidence of wound complications. The vascular supply to the lateral side of the heel has formed the Basis of the lateral calcaneal skin ¯ap used in plastic surgery (Grabb & Argenta 1981, Hovius et al. 1988,
136 The Foot (2001) 11, 136±139
doi: 10.1054/foot.2001.0700, available online at http://www.idealibrary.com on
Schoen & Lease 1996, Borrelli & Lashgari 1999). The use of a laterally placed incision has been avoided for Achilles tendon repair because of the perceived risk of sural nerve damage. The course of the sural nerve has been extensively studied (deMoura & Gilbert 1984, Ortiguela et al. 1987, Eastwood et al. 1992). We have modi®ed the vertical limb of the extended lateral approach to the hindfoot described by Eastwood and Atkins (1992) in order to expose the Achilles tendon for operative repair. The aim of this paper is to report our experience of this lateral approach to the Achilles tendon.
Methods Seventy-one consecutive patients who underwent surgical repair of their Achilles tendon over a ®ve-year period were included in the study. All of the patients were under the care of two specialist trauma surgeons in the same District General Hospital. Demographic details, operative procedure, and postoperative management were
ß 2001 Harcourt Publishers Ltd
Surgical repair of the Achilles tendon
Fig. 1 Lateral approach to the achilles tendon with incision over the sural nerve.
recorded from the patient notes. A telephone questionnaire survey was conducted to identify all complications that may have occurred after discharge from follow-up clinic. Patients were also asked to grade the result of their surgery and to describe any limitations to their daily or recreational activities.
Surgical technique All repairs were carried out using the same technique with the patient positioned prone. The 6 cm incision starts approximately 7 cm proximal to the calcaneal insertion of the Achilles tendon. It lies midway between the lateral edge of the tendon and the posterior edge of the ®bula, directly over the sural nerve (Fig. 1). The sural nerve is identi®ed by blunt dissection in the proximal part of the incision (Fig. 2) and gently retracted laterally for protection. The incision can be extended further for either a high or low rupture. It must be remembered that the nerve becomes progressively more anterior as it courses distally.
ß 2001 Harcourt Publishers Ltd
Fig. 2 Sural nerve identified in the surgical field.
The posterior skin ¯ap is gently retracted posteriorly and the paratenon is opened from the lateral side to provide access to the Achilles tendon. In each case, the tendon was repaired using a modi®ed Kessler stitch with a looped absorbable mono®lament suture. Skin closure was achieved by a number of different methods but in the majority of cases a continuous absorbable subcuticular stitch was used. The paratenon was not closed separately because the edges come together as the skin is closed. A tourniquet was used for 65 of the cases (92%) with a mean tourniquet time of 32 min + 10.1 (range 18±74). Postoperatively, the foot was placed in equinus and held in a below-knee plaster-of-paris cast for two weeks. The cast was then changed and the equinus reduced. At four weeks, the patient was put in a below-knee weight-bearing plaster, with the foot at 908, for a further four weeks. This was followed by full mobilization and physiotherapy.
The Foot
(2001) 11, 136±139
137
Surgical repair of the Achilles tendon
Results All 71 patients in this study had repair of their Achilles tendon using the lateral approach. The mean age of the patients was 45 (range 26±68) and there were 46 men and 25 women. Thirty-seven patients had rupture of the right Achilles tendon and 34 the left. The mean length of follow-up was for 32 months (/ÿ 2.5 months). There were no cases of deep wound infection, wound necrosis, or tendon re-rupture. There was one case (1.4%) of a super®cial wound infection at the distal end of the incision. This resolved after a two-week course of oral antibiotics. There were two cases of re¯ex sympathetic dystrophy (2.8%). These resolved at 6 and 10 months respectively. One patient experienced persistent paraesthesia on the lateral border of the foot (1.4%). A sural nerve lesion was con®rmed by nerve conduction studies but the patient declined exploration of the wound. Ninety-two per cent of patients stated that the result of surgery was excellent and 8% rated it as good. None felt that it was fair or poor. Sixty-six per cent denied any functional limitation and were back to pre-injury levels of activity. Eighteen per cent described themselves as being more cautious in their activities because of apprehension of rerupture, but with no physical limitation. Sixteen per cent had complaints including a feeling of stiffness in the ankle (6 patients), weakness in the calf (3 patients), and a slight limp (2 patients). Speci®c questions about the scar revealed that 90% of patients had no complaints and 10% had minor symptoms: mild tenderness (3 patients), lumpiness (3 patients) and itch (1 patient). All patients were satis®ed with scar cosmesis. No patients had problems with footwear.
Discussion Operative repair of Achilles tendon rupture is often recommended for younger active patients and for athletes. Advantages include a lower incidence of re-rupture (1±5%) compared with re-rupture rates of between 8 and 35% for non-operative treatment (Maffulli 1999, Quigley & Scheller 1980, Mellor & Patterson 2000). Reported complications of operative repair are super®cial and deep wound infections, ®stulae, skin or tendon necrosis, scar adhesions to the underlying tendon, and sural nerve damage (Cetti et al. 1993,
138 The Foot (2001) 11, 136±139
Gillies & Chalmers 1970, Kellam et al. 1985). Surgical complications are therefore mainly wound related. Wounds heal with fewer complications in well-vascularized areas. We feel that there is a decreased risk of injuring vascular and neurological structures on the lateral side of the hindfoot. This makes it theoretically attractive to use a lateral approach. A lateral approach to the Achilles tendon has been associated with high incidence of sural nerve damage (Nistor 1981, Carden et al. 1987, Soldatis et al. 1997). This causes loss of sensation on the lateral aspect of the foot, and may result in a painful neuroma. In one series of 44 patients, 7 out of 9 patients who had sural nerve damage had had a lateral incision (Nistor 1981). In contrast, use of the extended lateral incision for the repair of calcaneal fractures, as described by Freeman, resulted in 4 cases of sural nerve dysfunction out of a series of 150 patients, none of which was permanent (Freeman et al. 1998). In this study, the vertical limb of the extended lateral incision has been modi®ed in that the most proximal part lies just lateral to the Achilles tendon rather than directly over it. This eliminates the chance of adhesions between skin and tendon. Rather than re¯ecting the sural nerve in a skin ¯ap unseen, the sural nerve is actively identi®ed and protected. In this study, only one patient (1.4%) suffered sural nerve damage. The surgeon had documented in the notes that the sural nerve had been identi®ed and protected throughout the procedure. In retrospect, it was felt that the sural nerve had been caught by a suture. The patient declined re-exploration of her wound. This review of a consecutive series of patients has shown an extremely favourable rate of wound infection (1.4%) compared with that found in the literature, which varies from 1.5% to 21%. There were minor symptoms related to the scar in 10% of patients. There were no tendon re-ruptures. In view of the extremely low rate of surgical complications in this series, we recommend the use of the lateral approach, with formal identi®cation and protection of the sural nerve, for repair of the Achilles tendon. References Borrelli J Jr, Lashgari C 1999 Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma 13(2): 73±77
ß 2001 Harcourt Publishers Ltd
Surgical repair of the Achilles tendon
Carden D G, Noble J, Chalmers J et al 1987 Rupture of the calcaneal tendon. The early and late management. J Bone Joint Surg [Br] 69(3): 416±420 Cetti R, Christensen S E, Ejsted R et al 1993 Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 21(6): 791±799 de Moura W, Gilbert A. Surgical anatomy of the sural nerve. J Reconstr Microsurg 1984; 1(1): 31±39 Eastwood D M, Atkins R M 1992 Lateral approaches to the heel. A comparison of two incisions for the fixation of calcaneal fractures. The Foot 2: 143±147 Eastwood D M, Irgau I, Atkins R M 1992 The distal course of the sural nerve and its significance for incisions around the lateral hindfoot. Foot Ankle 13(4): 199±202 Freeman B J, Duff S, Allen P E et al 1998 The extended lateral approach to the hindfoot. Anatomical basis and surgical implications. J Bone Joint Surg Br 80(1): 139±142 Gillies H, Chalmers J 1970 The management of fresh ruptures of the tendo achillis. J Bone Joint Surg [Am] 52(2): 337±343 Grabb W C, Argenta L C 1981 The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser saphenous vein, and sural nerve skin flap). Plast Reconstr Surg 68(5): 723±730 Haertsch P A 1981 The blood supply to the skin of the leg: a post-mortem investigation. Br J Plast Surg 34(4): 470±477
ß 2001 Harcourt Publishers Ltd
Hovius S E, Hofman A, van der Meulen J C 1988 Experiences with the lateral calcaneal artery flap. Ann Plast Surg 21(6): 532±535 Kellam J F, Hunter G A, McElwain J P 1985 Review of the operative treatment of Achilles tendon rupture. Clin Orthop 201: 80±83 Leppilahti J, Puranen J, Orava S 1996 Incidence of Achilles tendon rupture. Acta Orthop Scand 67(3): 277±279 Maffulli N 1099 Rupture of the Achilles tendon. J Bone Joint Surg [Am] 81(7): 1019±1036 Mellor S J, Patterson M H 2000 Tendo Achillis rupture: surgical repair is a safe option. Injury 31(7): 489±491 Nillius S A, Nilsson B E, Westlin N E 1976 The incidence of Achilles tendon rupture. Acta Orthop Scand 47(1): 118±121 Nistor L 1981 Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study. J Bone Joint Surg [Am] 63(3): 394±399 Ortiguela M E, Wood M B, Cahill D R 1987 Anatomy of the sural nerve complex. J Hand Surg [Am] 12(6): 1119±1123 Quigley T B, Scheller A D 1980 Surgical repair of the ruptured Achilles tendon. Analysis of 40 patients treated by the same surgeon. Am J Sports Med 8(4): 244±250 Schoen N S, Lease J. Lateral calcaneal artery flap for coverage of a posterior heel defect in a child. J Foot Ankle Surg 1996; 35(6): 567±572 Soldatis J J, Goodfellow D B, Wilber J H 1997 End-to-end operative repair of Achilles tendon rupture. Am J Sports Med 25(1): 90±95
The Foot
(2001) 11, 136±139
139