Achilles Tendon Repair

[ldsrmdude]

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We've had 4 or 5 Achilles tendon ruptures over the past month or so here and I got to do a couple of them. I saw a few different techniques and was curious what you guys like or have seen (students feel free to chime in with what you've seen that you thought worked well). I know each case is different and it's hard to make generalities but what do you find works well? GraftJacket, FHL transfer, V-Y, turndown flap, Plantaris, etc.

What is your incision like? Do you do them percutaneously? Do you debride the ends of the tendon before primary repair?

Do your Achilles ruptures even get surgery or do you treat them conservatively with early mobilization? A meta-analysis in JBJS in Dec suggested that functional rehab and conservative care had the same re-rupture rate and less potential complications as surgical intervention.

Lots of questions, but I'm interested in everyones thoughts, students included.

 

[dtrack22]

I've seen a few. All surgically repaired, all open with incision placement along the medial border of the tendon. All were debrided then end to end repair, one GraftJacket, one FHL, one had no augmentation of the tendon.

All were younger, active patients. Haven't seen how the program treats older or inactive or chronically NC patients. And all were recent so I haven't seen follow up on them for more than a week. So far they're all healing w/o complication.

The problem with procedure selection from a student perspective is that often times we are at teaching hospitals (or at least more of an "academic" setting) where residents get to "try" a lot of different techniques as long as they can justify it's use to the attending. Or you get 3 different attendings that prefer 3 different augmentation techniques. Plus we are only at a location for a month at a time. So I have a feeling most of us are going to see a lot more variety than if we were to just spend time scrubbing with PADPM or Natch or newankle for a few months.

There's a new JFAS article (e-pub ahead of print) that talks about the incidence of DVT in achilles ruptures. It's high (just over 23%), and I'd be curious to hear if anyone has started to consider prophylaxis as their SOC for achilles patients.

 

[PADPM]

Interestingly enough it seems DVTs are more prominent in RF surgeries in comparison to FF and mid-foot surgeries. The fact that it's high for Achilles tendon rupture makes sense.

Most of the programs I've been too have treated them conservatively with casting and early mobilization. I haven't been to a program that used graft jacket. Most attendings I've talked to deem it an unnecessary cost. What exactly is the indication for using Graft jacket and incurring a high cost for the patient when more than likely they could get the same result from conservative care?

The ones I've seen were open, utilizing the medial incision to stay away from the sural nerve, debrided the ends and used a krackow stitch. No FHL or plantaris.

I also believe that GraftJacket is often over utilized. I think it gives some surgeons a stronger sense of security when it's used. I actually prefer a product called inforce by Integra. I find it's less bulky than Graft Jacket. I use a modified Krackow stitch, but don't do that many Achilles repairs. There are many ways to perform this repair, and you simply have to find what provides consistently good results in your hands.

My experience parallels most literature on this matter, that unless there is significant gapping, conservative care often has similar results as surgical repair, without the potential complications.

One exception is high level athletes who I believe do better with surgical intervention.

 

[Jacknife]

Often comorbidities exist that contribute to re-herniation, slow healing, and poor outcomes. The patient population with Lieden Factor V mutation, statin use, and spontaneous rupture with Ciproflaxin can be a vexing presentation. Life long compromised microvsculature, predisposes to a cycle of complications. Do you factor in patients with hypertryglicidemia who will return to statin use after the initial course of fibrates/niacin and return to statin use? I think the best bet with these folks is a Cam Walker.

http://www.bmj.com/content/337/bmj.a2286?ijkey=pZoJcnBxda0Ow&keytype=ref

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949584/

http://www.uptodate.com/contents/statin-myopathy

 

[PADPM]

Often comorbidities exist that contribute to re-herniation, slow healing, and poor outcomes. The patient population with Lieden Factor V mutation, statin use, and spontaneous rupture with Ciproflaxin can be a vexing presentation. Life long compromised microvsculature, predisposes to a cycle of complications. Do you factor in patients with hypertryglicidemia who will return to statin use after the initial course of fibrates/niacin and return to statin use? I think the best bet with these folks is a Cam Walker.

http://www.bmj.com/content/337/bmj.a2286?ijkey=pZoJcnBxda0Ow&keytype=ref

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949584/

http://www.uptodate.com/contents/statin-myopathy

Excellent post and points. Treating the entire patient, including co existing systemic problems is too often overlooked. At times (I have also been guilty of this in the past) we forget that the involved extremity is also attached to the rest of the body.

I do agree, and that's exactly why I mentioned that I usually reserve surgical intervention for those with a large gap or high level athletes, and of course it is dependent on the medical history.

Interestingly, I did do a repair on a patient with extremely elevated cholesterol (his PCP and son who is a doc wanted it repaired) and there were a few xanthomas present, which have been linked to hypercholesterolemia.

 

[streetsweeper]

We've had 4 or 5 Achilles tendon ruptures over the past month or so here and I got to do a couple of them. I saw a few different techniques and was curious what you guys like or have seen (students feel free to chime in with what you've seen that you thought worked well). I know each case is different and it's hard to make generalities but what do you find works well? GraftJacket, FHL transfer, V-Y, turndown flap, Plantaris, etc.

What is your incision like? Do you do them percutaneously? Do you debride the ends of the tendon before primary repair?

Do your Achilles ruptures even get surgery or do you treat them conservatively with early mobilization? A meta-analysis in JBJS in Dec suggested that functional rehab and conservative care had the same re-rupture rate and less potential complications as surgical intervention.

Lots of questions, but I'm interested in everyones thoughts, students included.

Depends on the patient. Are they active, old, plenty of co-morbidities? Is there significant gapping? I've come to love the FHL transfer with open repair. Again, depends on whether FHL is needed or not, we make the decision intra-operatively. Patients do very well afterwards.

As far as DVT prophylaxis goes, we prophylax almost anyone who is going to be casted/immobilized for a period of time. Especially after long cases. Whoever uses lovenox should be able to recognize the side effects (HIT), contra-indications (indwelling epidural), and monitor platelets. We also reduce the inherent risk for DVT by using venodyne boots, stopping the use of thigh tourniquets, reducing OP time through meticulous planning, early ROM, etc. in any major RF/reconstructive surgery.

Our camp is anti-tourniquet. We find that careful dissection and distraction can offer very good hemostasis. And, there's more potential harm to using tourniquets in general than not.

 

[ldsrmdude]

I think that, when needed, the FHL transfer is great. We do quite a few of them. I definitely will be doing them when I'm out in practice.

You bring up a really good discussion point with the tourniquet. We typically use it, but sometimes don't. I think we could use it less than we do for sure.

 

[PADPM]

I think we all use it more than necessary. I recently did a bunionectomy with osteotomy amd didn't use it, though I usually do. The tissue was much nicer to handle and everything was nice and "glistening", rather than dull and dry. There are obviously advantages and disadvantages to both camps, so as stated in the past, you simply must do what works best in your hands.

 

[newankle]

I've repaired both acute and delayed achilles ruptures as far as over a year out with the acute obviously being easier. Unless it's a sedentary older person I repair them all. I do a long lazy S incision and repair end-to-end with Krackow stitch with #2 Fiberwire reinforced with a running suture. I repair the paratenon/deep fascia when possible. I think early mobilization is a key to success. I make them NWB 3 weeks then NWB in CAM 3 more weeks but allow to wash and do active dorsiflexion/plantarflexion to gravity to get the tendon sliding and decrease adhesions. They begin WB in CAM at 6 weeks and PT. They get out of the CAM at 9 weeks. If they have a large gap I usually do a V to Y advancement of the proximal segment and reinforce with plantaris weaved through repair (if available). I use a Graft Jacket equivalent 4x7cm to wrap around the repair if there was gapping but if no gapping I don't use it. I never trust the graft to span a gap so I awlays get the repair end-to-end but reinforce with graft if needed. I always test my repair with forced dorsiflexion prior to closure. I also see a higher than normal rate of DVT with achilles repairs for whatever reason so I prophylax them with Xarelto x 3 weeks postop. Funny thing is though I see a lower rate of postop DVT with ankle fractures and rearfoot fractures/fusions than with achilles repairs. I do them same day under GA with popliteal block. For delayed reapirs I usually ad a flexor transfer. I probably reapair 30 a year.

 

[ldsrmdude]

I've repaired both acute and delayed achilles ruptures as far as over a year out with the acute obviously being easier. Unless it's a sedentary older person I repair them all. I do a long lazy S incision and repair end-to-end with Krackow stitch with #2 Fiberwire reinforced with a running suture. I repair the paratenon/deep fascia when possible. I think early mobilization is a key to success. I make them NWB 3 weeks then NWB in CAM 3 more weeks but allow to wash and do active dorsiflexion/plantarflexion to gravity to get the tendon sliding and decrease adhesions. They begin WB in CAM at 6 weeks and PT. They get out of the CAM at 9 weeks. If they have a large gap I usually do a V to Y advancement of the proximal segment and reinforce with plantaris weaved through repair (if available). I use a Graft Jacket equivalent 4x7cm to wrap around the repair if there was gapping but if no gapping I don't use it. I never trust the graft to span a gap so I awlays get the repair end-to-end but reinforce with graft if needed. I always test my repair with forced dorsiflexion prior to closure. I also see a higher than normal rate of DVT with achilles repairs for whatever reason so I prophylax them with Xarelto x 3 weeks postop. Funny thing is though I see a lower rate of postop DVT with ankle fractures and rearfoot fractures/fusions than with achilles repairs. I do them same day under GA with popliteal block. For delayed reapirs I usually ad a flexor transfer. I probably reapair 30 a year.

Thanks for the in-depth answer. When you say you do them same day, are you meaning you do them the same day as the injury or you are doing them outpatient surgery and sending them home the same day? Also, when you get the popliteal blocks, are you getting them pre-op from anesthesia or do you do them? Use an On-Q or similar pump or just 1 shot?

 

[dtrack22]

I also see a higher than normal rate of DVT with achilles repairs for whatever reason so I prophylax them with Xarelto x 3 weeks postop. Funny thing is though I see a lower rate of postop DVT with ankle fractures and rearfoot fractures/fusions than with achilles repairs.

Everything I've been able to find supports your experience with DVT in Achilles v every other rearfoot procedure. The difference between the two is higher than the difference between RF and FF procedures.

I have yet to see a procedure other than a couple TMA's and I&Ds done without a tourniquet. Would like a chance to see the difference in tissue handling, visibility, etc between the two in the same procedure once before this year is up.

 

[newankle]

Same day means outpatient surgery and anesthesia does my popliteal or sciatic block. No pump just pain meds and usually pain isn't bad for these despite the large incision and dissection.

 

[PMSIII]

We've had 4 or 5 Achilles tendon ruptures over the past month or so here and I got to do a couple of them. I saw a few different techniques and was curious what you guys like or have seen (students feel free to chime in with what you've seen that you thought worked well). I know each case is different and it's hard to make generalities but what do you find works well? GraftJacket, FHL transfer, V-Y, turndown flap, Plantaris, etc.

What is your incision like? Do you do them percutaneously? Do you debride the ends of the tendon before primary repair?

Do your Achilles ruptures even get surgery or do you treat them conservatively with early mobilization? A meta-analysis in JBJS in Dec suggested that functional rehab and conservative care had the same re-rupture rate and less potential complications as surgical intervention.

Lots of questions, but I'm interested in everyones thoughts, students included.

Great topic and thoughts so far. Here's my take on this - in an older indvidual with many co-morbidities and contraindications to OR, I am ok with treating him conservatively. Keep in mind that there is a fair number of literature out there about non-operative repair and a lot of this is European in nature. So the standard is different, patient population is different, and lawsuits virtually are non-existent.

In patients with suspected healing problems - I'm ok with percutaneous repair systems. Otherwise, my incision of choice is a posterior slightly medial straight line incision and I'll use a modified Krackow stich with a number 2 fiberwire and close the paratenon with a 3-0 vicryl suture. If there is a significant enough gap - then I'm doing an FHL transfer if need be. But I'll do my best to preserve the FHL. All my patient's get a thigh tourniquet, pre-op popliteal block, and placed in the prone position.

As for augmenting with acellular dermal matrix - show me literature that supports that the re-rupture rates are statistically significant with them compared to without acellular dermal matrix. I understand that they can help with scarring and I realize that Shaq had one of the dermal matrices applied to his achilles tendon but generally I'm a big believer of less foreign material = better especially in that anatomic area. The only time I'd consider using them is if it's an older tear and I want to help with the scarring but I wouldn't use them on an acute or fresh rupture off the bat.

As for prophylaxis - It's an interesting thought, when I was in residency I was not a fan of using PO or IM anticoagulants for more than the initial operative (and immediate post-operative) phase because the incidence in foot and ankle is statistically very low. However now that I'm starting private practice and seeing a lot of the medical-legal complications out there, I'm keeping them on prophylaxis as long as they are in a cast.

 

[ldsrmdude]

Great topic and thoughts so far. Here's my take on this - in an older indvidual with many co-morbidities and contraindications to OR, I am ok with treating him conservatively. Keep in mind that there is a fair number of literature out there about non-operative repair and a lot of this is European in nature. So the standard is different, patient population is different, and lawsuits virtually are non-existent.

In patients with suspected healing problems - I'm ok with percutaneous repair systems. Otherwise, my incision of choice is a posterior slightly medial straight line incision and I'll use a modified Krackow stich with a number 2 fiberwire and close the paratenon with a 3-0 vicryl suture. If there is a significant enough gap - then I'm doing an FHL transfer if need be. But I'll do my best to preserve the FHL. All my patient's get a thigh tourniquet, pre-op popliteal block, and placed in the prone position.

As for augmenting with acellular dermal matrix - show me literature that supports that the re-rupture rates are statistically significant with them compared to without acellular dermal matrix. I understand that they can help with scarring and I realize that Shaq had one of the dermal matrices applied to his achilles tendon but generally I'm a big believer of less foreign material = better especially in that anatomic area. The only time I'd consider using them is if it's an older tear and I want to help with the scarring but I wouldn't use them on an acute or fresh rupture off the bat.

As for prophylaxis - It's an interesting thought, when I was in residency I was not a fan of using PO or IM anticoagulants for more than the initial operative (and immediate post-operative) phase because the incidence in foot and ankle is statistically very low. However now that I'm starting private practice and seeing a lot of the medical-legal complications out there, I'm keeping them on prophylaxis as long as they are in a cast.

Any reason that you try hard to preserve the FHL? I had a patient in clinic recently who had an Achilles repair with FHL transfer 3 or so years ago (not done by us) who has had pain since the surgery. It sounds like they did a short harvest of the FHL through the same incision as the primary repair, and damaged the tibial nerve during the harvest possibly. Anyways, I had a good discussion with my attending about complications from the procedure, so I understand it isn't without risks. Simply curious about your thoughts and perspective on it.

Edit: Let me phrase my question better. Are you more concerned about loss of FHL function or other complications?

 

[dtrack22]

I'm keeping them on prophylaxis as long as they are in a cast

Lovenox or Xarelto?

 

[pacpod]

Most of the attendings I've seen recently have been sticking with anticoags as long as the patient is casted.

 

[pacpod]

Does anybody think foot and ankle surgeons (MD/DO & DPM) over utilize anti-coags? The statistical chance of a DVT from F/A sx is really low. I get it. Better to be safe than sorry. But still...I feel the amount of anti-coags used is overkill.

After hearing some of the docs talk about what cases developed a DVT/PE, I can't blame them.

 

[Podophile]

Does anybody think foot and ankle surgeons (MD/DO & DPM) over utilize anti-coags? The statistical chance of a DVT from F/A sx is really low. I get it. Better to be safe than sorry. But still...I feel the amount of anti-coags used is overkill.

The risk after general F/A surgery is low, but for most of those studies it included a lot of procedures where the patients were immediately WB afterwards. With anything that requires cast immobilization, the main DVT prevention of the calf pump mechanism is taken out of the equation and it seems like the risk of DVT significantly increases. Combine that with the fact that any of the older docs who have had their patients suffer from post-op DVTs or even die from PEs, and yes it's going to seem like prophylaxis is overutilized. But if you do even a lapidus that requires NWB, several toes along with it (increasing operating time), and the patient happens to be over 60 and female, you've probably already accumulated enough risk factor points that Lovenox wouldn't be a bad idea. And thats assuming the patient is totally healthy with no comorbidities.

 

[dtrack22]

Only seen PRP for calc fx's. I read a case report where Motley, Clements, and Pourciau incorporate PRP and PPP into calc fx patients who are being treated with ORIF via a lateral expansile approach, hands off retraction, algower-donati suturing, drain placement and bulky jones post op dressing. They didn't observe any complications.

With wound healing being the primary concern in calc fx, it makes sense that PRP would be beneficial. But I haven't come across a solid prospective study where those therapies are evaluated against a control where only current SOC procedures/therapies are being employed. It's one of those topics (unless someone can direct me to a good paper) where the therapy makes sense based on what we know about basic physiology (in this case wound healing), but the actual paper to connect the theory with clinical outcomes hasn't been published yet. At least not in FAS specific procedures.

 

[PMSIII]

Xarelto preferably because it is friendlier for patients PO vs IM injections. If insurance coverage is an issue then I rx enoxaperin sc

 

[PMSIII]

It's not overkill. Trust me when it comes down to medical-legal cases involving PE/DVT complications, the question of prophylaxis is always brought up. Not worth the risk for me. That being said, it is important to look at the global picture of the patient and health status - i.e. risk for falls, age, medical condition, comorbidity, etc. I strongly recommend discussing your plans for anticoagulation with the patient's primary care physician and crystalize an appropriate postoperative regimen - length of anticoagulation period, medication to be used, and monitoring (if on Coumadin) prior to taking them to the operating room.

 

[PMSIII]

Any reason that you try hard to preserve the FHL? I had a patient in clinic recently who had an Achilles repair with FHL transfer 3 or so years ago (not done by us) who has had pain since the surgery. It sounds like they did a short harvest of the FHL through the same incision as the primary repair, and damaged the tibial nerve during the harvest possibly. Anyways, I had a good discussion with my attending about complications from the procedure, so I understand it isn't without risks. Simply curious about your thoughts and perspective on it.

Edit: Let me phrase my question better. Are you more concerned about loss of FHL function or other complications?

I try to preserve the tendon for 2 main reasons:
1) Less OR time = Less stress on the patient
2) Less dissection = less swelling post-operatively and less chance for intraoperative complications

Function is a potential concern of course but it wouldn't stop me from performing the procedure if indicated.

 

[ldsrmdude]

I try to preserve the tendon for 2 main reasons:
1) Less OR time = Less stress on the patient
2) Less dissection = less swelling post-operatively and less chance for intraoperative complications

Function is a potential concern of course but it wouldn't stop me from performing the procedure if indicated.

Ok, those make a lot of sense. When you do the FHL harvest, do you prefer a short harvest through the primary incision or doing a long harvest with a medial instep incision?

 

[PMSIII]

Ok, those make a lot of sense. When you do the FHL harvest, do you prefer a short harvest through the primary incision or doing a long harvest with a medial instep incision?

I am Ok with the short harvest because it should give you enough length for your fixation in the Calcaneaus. I personally don't see the benefit for the medial incision to harvest at the knot of Henry for Achilles pathology.

The only time I would consider a long harvest is if I'm trying to harvest the FHL for peroneaus brevis ruptures (large gaps) - For those cases, I would release the FHL at the knot of henry and route it from the lateral incision (since it is the most lateral structure from the superior lateral peroneal incision) - Sig Hansen talks about this approach in his text.