Achilles repair: Don’t be torn

Email to a Friend

iStockphoto

Increasingly more surgeons are adding a new procedure to their repair of a torn Achilles tendon. However, you should be on guard for overstatements about the percutaneous approach, because sufficient data haven’t been collected to indicate whether it’s better than the conventional, or open, procedure.

In a percutaneous repair of a torn Achilles tendon, a surgeon makes seven to nine small (less than three-fifths of an inch) incisions compared with the open procedure’s one continuous incision that’s as much as 8 inches long and requires longer sutures than does the former. Because of this, percutaneous surgery shows fewer complications with wound-healing than does open surgery, says Dr. Amol Saxena, who is a fellow of American College of Foot and Ankle Surgeons (ACFAS). The postoperative immobilization of the foot and ankle in a cast or boot (up to 8 weeks) after open surgery can make the incision more susceptible to infection.

“Cast immobilization for [percutaneous] repairs is performed rarely these days,” adds Dr. Jeffrey McAlister, who also is a fellow of ACFAS.

Otherwise, “the percutaneous is different, but it hasn’t been proven to be better or worse” than is open Achilles tendon surgery, Saxena says.

Based on his discussions with surgeons at industry meetings, Saxena guesses that as much as 20 percent of foot and ankle surgeons perform percutaneous Achilles tendon repairs, and he expects the percentage to increase.

People who have wound-healing problems, such as those who have a bad skin condition, often aren’t suitable for open surgery. As a result, their only option is to have the tendon heal over time through immobilization for 12 weeks. However, that leads to a higher incidence of rerupture, the leg is weaker than it would be after repair by surgery, and the person has less ability to participate in sports. The percutaneous approach might provide a surgical option for some of these people.

Percutaneous Achilles tendon surgery and its postoperative protocol have “allowed us to expand our demographic,” McAlister says. “We typically avoid surgery in anyone that is an uncontrolled diabetic or heavy smoker.”

Saxena says recovery time for the Achilles tendon repair after open surgery is the same as it is after the percutaneous surgery, and so is the cost.

Saxena doesn’t believe that a magic number of percutaneous surgeries makes one surgeon a better choice over another to perform the procedure. However, a surgeon who performs only percutaneous surgeries isn’t the best choice, because the percutaneous approach might emerge during the procedure as inappropriate, and the surgeon would have to convert the surgery to an open procedure, Saxena says.