Commentary & Perspective on
"Limited Open Repair of Achilles Tendon Ruptures.
A Technique with a New Instrument and Findings of a Prospective Multicenter Study"
By Mathieu Assal, MD et al.

Commentary & Perspective by
Mark S. Myerson, MD*,
Union Memorial Orthopaedics, Baltimore, MD

This study by Assal et al. is an excellent prospective review of their extensive experience with ruptures of the Achilles tendon. They have examined the problem thoroughly, and their technique of minimally invasive repair with use of an instrument that avoids soft-tissue problems associated with open repair is a superb addition to our treatment armamentarium.

The goal of treatment should be to maximize the return to function and athletic activity as rapidly as possible with minimal morbidity¹. The decision to treat an acute Achilles tendon rupture surgically rather than nonoperatively is based on the likelihood of attaining improved strength and a more rapid return to function. As patients' expectations and athletic goals have increased over the past decade, surgical treatment options have gained popularity. Yet, although the vast majority of studies over the past decade have reported improved results with open repair of Achilles tendon rupture, these are associated with an unpredictably high rate of wound complications. Clearly the most disconcerting issue with regard to open repair is the high prevalence of wound complications, and this potential problem of wound breakdown exists regardless of the method of open repair.

Certainly, from our own experience and that reported by others, operative treatment of Achilles tendon ruptures is likely to yield the most satisfactory results as measured by a more rapid return to strength and function^2,3.

Perhaps the most important aspect of operative treatment is the method of tensioning the ends of the Achilles tendon⁴. When surgery is performed, the physiological continuity of the tendon ends must be attained, enabling the restoration of normal dynamic muscle function. Because of fraying of the tendon ends with this injury, attaining this is easier said than done. Nothing is gained by the surgical procedure if maximum push-off strength is not regained. We have found it helpful to assess the tension of the repaired tendon in comparison with that of the uninvolved, prepped, and draped leg in the operative field¹.

Correct tensioning of the tendon is not possible with use of a traditional percutaneous method of repair, and even with full, uneventful healing of the tendon, it would be a matter of luck if the tendon ends were correctly apposed. The minimally invasive method of repair described by Assal et al., however, provides a means for ensuring correct apposition. This procedure allows the surgeon to visualize the frayed tendon ends. Also, while the sutures are inserted percutaneously, the tension of the tendon can easily be established, as described above.

The second major issue with regard to operative repair of Achilles tendon ruptures is the prevalence of wound complications postoperatively. While many of these are minor, deeper infections do occur and can be quite devastating. The proponents of percutaneous techniques correctly note an insignificant prevalence of wound problems with these methods of treatment.

At our center, we have attempted to minimize wound problems by decreasing the swelling of the limb preoperatively, performing a fasciotomy of the posterior compartment, achieving meticulous wound closure, and treating the limb with immobilization until the wound is healed, at which time the sutures are removed⁴. Surgical management of these ruptures should not be considered a matter of urgency; by delaying surgery for as long as two weeks, the swelling will decrease, the frayed tendon ends will be easier to appose, and there will be a minimal risk of their retraction.

The method of limited open repair of Achilles tendon ruptures presented by Assal et al. in this article allows effective apposition of the tendon ends without any reported wound complications. It is important to recognize, however, that this improved surgical technique does not of itself lessen the need for a postoperative functional rehabilitation program that emphasizes early weight-bearing and early range-of-motion and strengthening exercises.

Assal et al. have presented a logical and well-planned treatment program for acute ruptures of the Achilles tendon that will certainly have a tremendous impact on our choices of treatment for patients with these injuries.

*The author did not receive grants or outside funding in support of this research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Myerson MS, Mandelbaum B. Disorders of the Achilles tendon and the retrocalcaneal region. In: Myerson MS, editor. Foot and ankle disorders. Philadelphia: Saunders; 2000. p 1367-98.
2. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med. 1995;23:392-5.
3. Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. J Bone Joint Surg Am. 1999;81:983-90.
4. Myerson MS. Achilles tendon ruptures. Instr Course Lect. 1999;48:219-30.