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70 | The Journal of One-Day Surgery | VOL 17 | No 3
Minimally-invasive Surgical
Repair of Ruptured Achilles
Tendon as a Day Case Procedure
with Early Full Weight Bearing
MAYUKH BHATTACHARYYA & BRUNO GERBER
The authors have received no funding from, nor have any other financial connection with, the manufacturer of the Achillon™ instrument guide. Keywords: New day surgery procedures; Orthopaedics; Emergencies
Abstract
We performed a non-randomised, prospective, sequential study in order to assess the potential of minimally invasive repair after rupture of the tendo Achillis as a short-stay surgical procedure with early weight-bearing The first group of 25 patients were hospitalised until the next available trauma list and then underwent a conventional open repair. The second group of 20 patients were treated with a temporary splint and admitted from home at the first available opportunity to be treated as a day case with a minimally-invasive technique using the Achillon™ instrument guide. Patients in the open repair group were not mobilised fully weight- bearing until eight weeks after surgical repair whereas the minimally-invasive group were allowed early Median postoperative hospitalisation was 3.3 days in the open group, whereas the minimally-invasive group were all discharged on the day of surgery. Patients undergoing open repair required postoperative analgesia for an average of seven days compared to two days in the minimally-invasive group. These patients also required opioid-based analgesia, whereas only paracetamol or ibuprofen were required in the minimally- Two cases of wound dehiscence requiring repeated debridement surgery and five cases of delayed wound healing occurred in the open repair group, none of whom had any predisposing factors. In contrast, the only case of delayed wound healing in the minimally-invasive group occurred in a patients with known HIV infection. Both groups showed an improved functional outcome after surgery but the minimally-invasive group demonstrated a functional benefit from early weight bearing mobilisation and same day discharge. This study suggests that minimally-invasive surgical repair with the Achillon™ instrument as a day case procedure and early weight-bearing mobilisation in an orthosis for accelerated rehabilitation might be adopted for all patients with rupture of the tendo Achillis. Immediate postoperative morbidity and analgesic requirements following surgical intervention have been Surgical treatment of acute rupture of the tendo Achillis is underreported. The potential of any method to offer favoured in the literature for younger patients1, 2. This
treatment as day surgery has also not been extensively condition typically affects young active adults and is advocated. The Achillon™ (Integra Lifesciences, Plainsboro, associated with prolonged periods off work and sporting New Jersey) is an adjustable polycarbonate instrument activity2. Surgical repair with percutaneous3 or limited
guide (Figure 1) which allows minimally-invasive repair of open technique1 had been reported with good to excellent
the Achilles tendon with direct visualisation and control of outcome compared to open operative treatment. The two the tendon stumps. We believe that repair with the main problems with operative intervention by open repair Achillon™ instrument on a semi-elective basis with early described in the literature are poor wound healing and delayed weight bearing following surgery2. This also has
significant health implications for the patients and Authors’ Addresses
represents a financial burden to the healthcare provider in MAYUKH BHATTACHARYYA Staff Orthopedic Surgeon BRUNO GERBER Consultant Orthopaedic Surgeon, terms of associated nursing and physiotherapy costs1.
The Journal of One-Day Surgery | 71
Table 1 Inclusion and exclusion criteria for surgical
Inclusion Criteria
Exclusion Criteria
Figure 1 The Achillon™ instrument guide and needle driver. The metal
screw allows the polycarbonate guide to be adjusted so that the tendon lies comfortably between the two central branches.
weight bearing would reduce bed usage and facilitate faster patients received one dose of cefuroxime 15 minutes before rehabilitation for patients after a rupture of the tendo Achillis. Thus, in the present medico-political climate, it may provide less financial burden to the national health Conventional open surgical management
The first group of 25 patients were admitted direct from A&E and underwent surgery on the next available trauma We therefore prospectively studied two groups of patients list. These patients had a simple, open end-to-end repair of admitted to our institution and treated operatively for the tendon as an inpatient under instruction of the acute Achilles tendon rupture in order to compare bed admitting consultant. The Achilles tendon was repaired usage, wound complications and immobilisation regimen.
with delayed absorbable sutures through a medial In the first part of the study, patients who had been treated longitudinal incision approximately 10 cm long (Figure 2) by open surgery with delayed immobilisation for eight which was subsequently closed with nylon. The limb was weeks were assessed. In the second part, those treated by then placed in a temporary gravity equinus plaster the Achillon™ technique with immediate weight bearing overnight. All the patients received a nerve block with or without oral morphine as postoperative analgesia while an inpatient and subsequently received co-dydramol and The aim was to address the potential of any surgical ibuprofen after discharge. Patients were discharged when method which reduces hospitalisation and postoperative they were confident using crutches and the physiotherapist wound care costs with reduced requirements for postoperative analgesia, together with improved rehabilitation and return to normal activity for young patients (age below 45) with a rupture of the Achilles Preoperative assessment:
The patients were acquired from the accident and emergency (A&E) department of the University Hospital Lewisham between January 2003 and November 2005 with Achilles tendon rupture satisfying our inclusion criteria (Table 1). The diagnosis was made clinically by a palpable gap in the Achilles tendon with positive Thompson test.
None had any radiological investigation. All the patients were initially treated with analgesia and the application of Figure 2 Open repair of the Achilles tendon with delayed absorbable sutures
performed through a medial longitudinal incision.
a below-knee anterior cast adjusted in equinus position.
Patients subsequently underwent surgery, with all the The equinus position of the hind-foot was not changed for procedures performed, assisted or supervised by the main the first two weeks and patients were mobilised non- authors. All patients were operated on under general weight bearing. The position of the plaster cast or the anaesthesia in the prone position with a tourniquet. All number of heel raises in the orthosis was then reduced at 72 | The Journal of One-Day Surger
two-weekly intervals before being removed at eight weeks when full weight bearing was allowed. Rehabilitation exercises were performed sequentially under the supervision of a physiotherapist over the three months Minimally-invasive Achillon™ management.
The subsequent 20 patients had their repair as a limited open technique followed by immediate weight bearing.
After placing the temporary below-knee equinus splint in the A&E department, patients were sent home and asked to return on the morning of the consultant’s next operating day. All patients were operated on by a single consultant Figure 4 The postoperative
(BG). A 3 cm incision was made medial to the palpable gap in the Achilles tendon. The paratenon was identified after minimal localised soft tissue dissection, the torn tendon stump was identified and the Achillon™ instrument guide (Figure 3) was introduced as described by Assal et al1. Three
sutures were placed in both tendon stumps which were then tightened under direct visual control while placing the ankle into the equinus position The tendon sheath and skin were carefully closed; local anaesthesia was not used.
Patients in this group were placed back into the below- The average age of the patients was 36.8 years (range knee gravity equinus cast for the immediate postoperative 25–48). All had a closed rupture within 5–7 cm from period until a suitable orthosis was available, after which calcaneal tuberosity, a palpable gap in the tendon averaging they were mobilised with full weight bearing and were 38 mm (range 31–48 mm) and a positive Thompson test.
encouraged to move the ankle within the orthosis. They All patients had ruptured their tendon within the previous were prescribed paracetamol and ibuprofen as take-home seven days and all were non-professional athletes with a analgesia and discharged later the same day.
keen sporting interest. At time of injury they were participating in a pivot-sporting activity, such as badminton, tennis and basketball. The mean time interval between the injury and index operation was 3.6 days (range Five patients in the open surgery group were lost to follow- up, leaving 20 with complete data sets at one year for analysis. One patient with HIV did not attend the final one year assessment, but no other patients were lost to follow- up in the minimally-invasive group. The mean age of each group was similar, as were the ratios of right to left sided tendon ruptures. There were more men than women in The average operating time was 85.7 ±18 minutes (range 81–123) in the open group, compared to 38.5 ± 7.9 minutes Figure 3 The Achillon™ instrument in position in the prone patient in the
(range 27–58) in the minimally-invasive group. Average minimally-invasive group. The forceps hold the tendon stump prior to tourniquet time in the minimally-invasive group was 32 minutes (range 19–52 min). All patients in the open At the first follow-up, all wounds were assessed and surgical group were hospitalised before and after surgery sutures were removed. Patients were then clinically with a median postoperative hospital stay of 3.3 (range 2–5) reviewed every two weeks for eight weeks. The equinus days. No patients in the minimally-invasive were kept in position of the plaster or the number of heel raises in the hospital before surgery and all were discharged home on orthosis (Figure 4) was reduced at each visit until a plantigrade position of the ankle was achieved. The orthosis or plaster cast was removed at eight weeks. Each The number of days for which postoperative analgesia was patient in both groups was subsequently reviewed at three required was greater in the open group compared to the months, six months and one year. The primary outcome minimally-invasive group (mean 7 days versus 2 days).
measure was the time taken to return to normal activities, There was also a difference between the groups in the type as reported by the patient. Data relating to the return to of postoperative analgesia required, with opioid-based normal sporting activity, walking, stair climbing and work analgesia being used in the open repair group, whereas the minimally-invasive group reported adequate analgesia The Journal of One-Day Surgery | 73
with paracetamol or ibuprofen. After one week, all patients in the minimally-invasive treatment group and six in the open group no longer required prescribed analgesia before performing daily activities. The time taken to return to normal walking was a median of 11 weeks (range 8–20) in the minimally-invasive treatment group and 17 weeks (range 12–24) for the open group. There was also an earlier return to normal stair climbing, with a median of 13 weeks (range 9–21) in the minimally-invasive treatment group and 19 weeks (range 13–27) for the open technique. The majority of patients had returned to their pre-injury state after three months in the minimally-invasive group and six months after the injury in the open group. This level of postoperative improvement was maintained until the final Figure 5 Wound infection and dehiscence occurring after open surgery.
We observed the maximum functional deficit of the gastrosoleus complex one to two weeks after either the Two cases of wound dehiscence requiring further surgery (Figure 5) and five cases of delayed wound healing of the surgical site (Figure 6) were reported as wound complications in the open group. In the minimally- invasive group, the patient with HIV infection had delayed wound healing, but did not attend the final assessment at one year. All other patients in the minimally-invasive group were satisfied with their wound healing and had only a minimal scar at the incision site (Figure 7). There was some difference in the range of ankle movement at six months follow up, especially in patients undergoing open repair associated with major wound complications, where ankle stiffness persisted at the final, one year follow-up.
Figure 6 Delayed wound healing of the surgical site complicating recovery in
This study provides further evidence that minimally- invasive repair with early weight bearing rehabilitation has advantages over a traditional open repair with delayed mobilisation for patients who have undergone surgery for ruptured Achilles tendon. Traditionally, patients have been operated on as inpatients and followed-up in the outpatients clinic with supervised physiotherapy in our institution. We have shown that limited open repair with the Achillon™ instrument may allow these cases to be treated as a day case procedure and also allows faster rehabilitation. The financial implication was reduced bed usage, reduced consumption of postoperative analgesics and other associated indirect costs to the healthcare provider. The practical advantages of early weight-bearing mobilisation for the patients were an earlier return to Figure 7 Good wound healing with minimal scarring at the incision site,
normal walking and stair climbing compared to their group typical of the minimally-invasive group.
counterparts who underwent open surgery.
the support of physiotherapists. This reduced use of hospital resources in the minimally-invasive group should In this study, we reduced the median postoperative hospital reduce cost to the healthcare provider, although there is the stay from 3.3 days with open repair to same day discharge additional cost of the Achillon™ device itself. We chose to with a minimally-invasive approach. In addition, a change use single use devices in all of our patients, which cost in management intent also eliminated a preoperative £170.15 each,* although devices are also available for hospital admission of up to four days waiting for an multiple use. However, the total cost of this surgery is available trauma list. However, other factors may have * Judith Banfield, Supply Manager, University Hospital Lewisham, personal influenced the patients’ discharge decision, in particular, 74 | The Journal of One-Day Surgery | VOL 17 | No 3
reduced by shorter operating time, reduced nursing time compliant to follow a structured rehabilitation protocol.
and lower cost related to the analgesic drugs used. Costs This is an additional benefit to the healthcare providers.
would be reduced even further if all patients were treated as day cases rather than as inpatient trauma cases. We The difference in complication rates after surgery is as believe that an economic analysis will be necessary to fully important as the primary outcome measure. Wound complication and atrophy of the calf muscles after an injury to the tendo Achillis are reported to alter outcome7,
Another problem with surgically repaired tendon rupture is 8. We observed two major wound complications and five
postoperative pain, which also delays rehabilitation. In our cases of delayed wound healing in the open repair group.
study, patients undergoing an open repair required opioid The first patient developed persistent wound infection, analgesia (despite the use of a perioperative nerve block) which was treated conservatively with oral antibiotics and which inevitably resulted in slower rehabilitation. In silver dressings for six months until healing occurred. A contrast, the minimally-invasive group required only non- second patient was treated by larval therapy and delayed opioid analgesia and their overall analgesic requirements mobilisation. He made a prolonged recovery. None of these were also reduced (postoperative pain might have been patients had any co-morbidity which could have influenced improved even more by instillation of long-lasting local the wound healing mechanics. In contrast, the only patient anaesthesia into the wound – Ed).
in the small minimally-invasive cohort to experience any wound healing problem had co-existing HIV. This patient We also compared the benefits of delayed weight bearing had delayed wound healing, the final outcome of which is following the traditional open technique with early full unknown as they failed to attend the final follow-up clinic.
loading in an orthosis after the minimally-invasive technique. Early mobilisation of the ankle4, early
Open surgery with delayed rehabilitation following rupture functional treatment5 and early full weight bearing after
of the Achilles tendon may produce disuse atrophy very operative repair of Achilles tendon have all been advocated.
quickly, which is difficult to reverse8. We noted two
None of our patients in the minimally-invasive group patients in the open repair group who reported 50% loss of reported any adverse consequences from early muscle bulk compared to the other side. Loss of muscle mobilisation. We advised all patients, in both groups, that bulk was assessed clinically, although calf circumference is they should not drive in either a plaster cast or an orthosis.
reported to be an insensitive assessment tool6, 9.
Consequently, many patients in sedentary jobs were forced Nevertheless, controlled early loading and movement, to stay home simply because of transport difficulties, which are possible with minimally-invasive repair, should although some of the patients did return to work with an help to preserve the calf muscle volume.
orthosis within a week of minimally-invasive tendon repair. Patients perceived this early return to normal In summary, our open surgery group provided further activities of daily living as the most important outcome evidence of wound complications, two of which were measure. The ability to bear weight within the orthosis major, and greater opioid use which may impair functional certainly encouraged some patients to return to activity.
outcome following repair of ruptured tendo Achillis. The We advocate early loading of a healing tendo Achillis after second part of our study provided evidence of improved minimally-invasive repair to prevent detrimental outcome from same day discharge and early full weight alterations in muscle characteristics. In addition, a bearing mobilisation after minimally-invasive repair. In favourable influence on the maturation of collagen fibres addition, the practical advantages of early full weight within the tendon has also been reported6.
bearing did not predispose these patients to a higher complication rate. In particular, there was no evidence of The clinical measurements at six months after the surgical tendon lengthening or a higher re-rupture rate. We repair suggested an improved active range of movement of advocate the use of a minimally-invasive procedure, on a the ankle. Minimal scar tissue may have also influenced semi-elective basis without hospitalisation, with early the range of motion. Although the range of movement is weight bearing mobilisation for the rehabilitation of all only a surrogate measurement of tendon lengthening, our patients with acute ruptures of the Achilles tendon. Use of results in the minimally invasive group did not indicate the Achillon™ instrumentation allows repair of the tendon that early weight bearing produced stretching within the under direct vision, thereby preserving its vascularity. This healing tendon. We believe the ends of the tendon are held results in shorter operating time, better wound healing, in contact by an operative repair and minimal soft tissue reduced analgesic requirements, shortened hospital stay damage produces less postoperative pain, allowing the and reduced postoperative complications.
musculotendinous unit to be fully loaded.
We have chosen an orthosis in the immediate postoperative period for its flexibility. However, some patients had to be offered a full equinus plaster due to We thank Dr. Obonna Ekoecha for initial data collection, unavailability of the custom-made orthosis. We speculate Mrs. Helen Bradley and Mrs. Louise Nurchin for that an orthosis may help our patients return earlier to a continuing wound care to the patients. We also thank our normal gait cycle. The practical advantages of being able to patients for giving consent to publish the clinical pictures.
mobilise after minimally-invasive surgery and same day We acknowledge the support of Maggie Fernandez and discharge puts greater emphasis on the patient to be more 1. Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P. Limited 6.Rantanen J, Hurme T, Kalimo H. Calf muscle atrophy and Achilles open repair of Achilles tendon ruptures: a technique with a new tendon healing following experimental tendon division and surgery instrument and findings of a prospective multicenter study. Journal in rats. Comparison of postoperative immobilization of the muscle- of Bone and Joint Surgery — American Volume 2002;84:161–70.
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