COMPARISON OF MINI-OPEN AND PERCUTANEOUS REPAIR METHODS IN TREATMENT OF ACUT ACHILLES TENDON RUPTURE

Yıl 2022, Cilt: 29 Sayı: 1, 101 - 110, 01.03.2022

Fatih İnci , İbrahim Alper Yavuz

https://doi.org/10.17343/sdutfd.1008494

Cited By: 1

Öz

Objective
Treatment of acute Achilles tendon rupture (ATR) is
still a controversial issue. Treatment of acute ATR
with mini-open and percutaneously applied minimally
invasive techniques has become a better option
because of lower re-rupture rates and less wound site
problems than traditional open surgical treatment.
Although successful results have been obtained
with these techniques, sural nerve injury is the most
important complication of these techniques. In this
study, it was aimed to compare the clinical results and
complication rates of minimally invasive techniques
(mini-open and percutaneous repair) used in the
treatment of acute ATR.
Material and Methods
A total of 42 patients whose acute ATR was repaired
with minimally invasive methods between 2016
and 2019 were included in the study. The patients
were divided into two groups: the mini-open repair
group in which the tendon ends could be observed
from the surgical incision (Group A, n=22) and the
percutaneous repair group in which they could not
be observed (Group B, n=20). AOFAS score, ankle
plantar flexion and dorsiflexion angles, return to
work and sports were used for clinical evaluation.
Post-surgical complications were divided into two
categories: minor (not requiring re-surgery) and major
(requiring re-surgery) complications. The groups
were compared in terms of functional outcomes and
complications.
Results
The mean age of the patients was 40.30±5.56 (23-
50). No statistically significant difference was found
between the groups in terms of demographic data
(p>0.05 for all). There was no statistically significant
difference between the groups in terms of the
functional results of the patients in the second year
after surgery and the time to return to work and sports
(p>0.05 for all). Minor complications in 2 patients in the
mini-open group and in 3 patients in the percutaneous
repair group observed. While sural neuropathy was
seen in 3 (15%) patients after percutaneous repair,
it was not seen in any patient after mini-open repair.
Major complication requiring reoperation was seen in
one patient of each group. There was no statistically
significant difference between the groups in terms of
both minor and major complications. (p=0.566 and
p=0.947, respectively).
Conclusion
The functional outcomes and complication rates of the
treatment of acute Achilles tendon rupture with miniopen
or percutaneous repair are similar. Because
of the lower risk of sural nerve injury, the mini-open
repair method may be more advantageous.

Anahtar Kelimeler

Achilles tendon rupture, Mini-open, Percutaneous, Repair, Sural nerve

AKUT AŞİL TENDON RÜPTÜR TEDAVİSİNDE MİNİ-AÇIK VE PERKÜTAN TAMİR YÖNTEMLERİNİN KARŞILAŞTIRILMASI

Öz

Amaç
Akut aşil tendon rüptürü (ATR) tedavisi halen tartışmalı
bir konudur. Geleneksel açık cerrahi tedaviye
göre daha düşük re-rüptür oranları ve daha az yara
yeri sorunları gözlenmesi nedeniyle akut ATR’nin mini-
açık ve perkütan olarak uygulanan minimal invaziv
tekniklerle tedavisi daha iyi bir seçenektir. Bu teknikler
ile başarılı sonuçlar alınmasına rağmen, sural sinir
yaralanması bu tekniklerin en önemli komplikasyonudur.
Bu çalışmada, akut ATR tedavisinde kullanılan
minimal invaziv tekniklerin (mini-açık ve perkütan
tamir) klinik sonuçlarının ve komplikasyon oranlarının
karşılaştırılması amaçlanmıştır.
Gereç ve Yöntem
016-2019 yılları arasında akut ATR’si minimal invaziv
yöntemler ile tamir edilen toplam 42 hasta çalışmaya
alınmıştır. Hastalar, cerrahi kesiden tendon uçlarının
gözlenebildiği mini-açık tamir grubu (Grup 1, n=22) ve
gözlenemediği perkütan tamir grubu (Grup 2, n=20)
olmak üzere 2 gruba ayrıldı. Klinik değerlendirme için
AOFAS skoru, ayak bileği plantar fleksiyon ve dorsifleksiyon
açıları, işe ve spora geri dönüş süreleri
kullanıldı. Cerrahi sonrası komplikasyonlar ise minör
(tekrar cerrahi gerektirmeyen) ve majör (tekrar cerrahi
gerektiren) komplikasyonlar olmak üzere iki kategoriye
ayrıldı. Gruplar fonksiyonel sonuçlar ve komplikasyonlar
açısından karşılaştırıldı.
Bulgular
Hastaların ortalama yaşı 40,30±5,56 (23-50) olarak
bulundu. Gruplar arasında yaş, cinsiyet, ameliyata
kadar geçen süre, ameliyat süresi, takip süresi açısından
istatistiksel olarak anlamlı bir fark bulunamadı
(hepsi için p>0.05). Hastaların ameliyat sonrası ikinci
yıl fonksiyonel sonuçları ile işe ve spora dönüş süreleri
açısından gruplar arasında istatistiksel olarak anlamlı
bir fark bulunamadı (hepsi için p>0.05). Mini-açık
grupta 2 hastada ve perkütan tamir grubunda 3
hastada minör komplikasyon gözlendi. Sural nöropati
perkütan tamir sonrası 3 (%15) hastada görülürken,
mini-açık tamir sonrası hiçbir hastada görülmedi. Her
iki grubun birer hastasında tekrar ameliyat gerektiren
major komplikasyon görüldü. Gruplar arasında hem
minör hem majör komplikasyonlar açısından istatistiksel
anlamlı fark bulunamadı (sırasıyla p=0,566 ve
p=0,947).
Sonuç
Akut ATR’nin mini-açık veya perkütan tamirle tedavisinin
fonksiyonel sonuçları ve komplikasyonları benzerdir.
Daha düşük sural sinir yaralanma riski olması
nedeniyle mini-açık tamir yöntemi daha avantajlı olabilmektedir.

Anahtar Kelimeler

Aşil tendon rüptürü, Mini-açık, Perkütan, Tamir, Sural sinir

Kaynakça

• 1. Fischer S, Colcuc C, Gramlich Y, Stein T, Abdulazim A, von Welck S, Hofmann R. Prospective randomized clinical trial of open operative, minimally invasive and conservative treatments of acute Achilles tendon tear. Arch Orthop Trauma Surg 2020;141(5):751–760
• 2. Wang D, Sandlin MI, Cohen JR, Lord EL, Petrigliano FA, SooHoo NF. Operative versus nonoperative treatment of acute Achilles tendon rupture: An analysis of 12,570 patients in a large healthcare database. Foot Ankle Surg. 2015;21(4):250–253.
• 3. Chan JJ, Chen KK, Sarker S, Hasija R, Huang HH, Guzman JZ, Vulcano E. Epidemiology of Achilles tendon injuries in collegiate level athletes in the United States. Int Orthop 2020;44(3):585–594
• 4. Heikkinen J, Lantto I, Flinkkila T, Ohtonen P, Niinimaki J, Siira P, Laine V, Leppilahti J. Soleus atrophy is common after the nonsurgical treatment of acute Achilles tendon ruptures: a randomized clinical trial comparing surgical and nonsurgical functional treatments. Am J Sports Med 2017;45(6):1395–14
• 5. Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019 Jan 7;364:5120.
• 6. Gatz M, Driessen A, Eschweiler J, Tingart M, Migliorini F. Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study. Arch Orthop Trauma Surg. 2021;141(3):383–401
• 7. Haji A, Sahai A, Symes A, Vyas JK. Percutaneous versus open tendo Achillis repair. Foot Ankle Int 2004;25.215–8
• 8. Joannas G, Arrondo G, Eslava S, Casola L, Drago J, Barousse R, et al. Percutaneous Achilles tendon repair with the Dresden instrument. Clinical and MRI evaluation of 90 patients. Foot Ankle Surg 2020;26(2):209-217
• 9. Khan RJ, Fick D, Keogh A, et al. Treatment of acute Achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87(10):2202–10
• 10. Ma GW, Griffith TG. Percutaneus repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res 1977;128:247–55.
• 11. Bradley JP, Tibone JE. Percutaneus and open repairs of Achilles tendon ruptures. Am J Sports Med 1990;18:188–95.
• 12. Jones MP, Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon rupture: key findings from a recent Cochrane review. J Bone Joint Surg Am. 2012;94(12):e88.
• 13. Yang B, Liu Y, Kan S, et al. Outcomes and complications of percutaneous versus open repair of acute Achilles tendon rupture: a meta-analysis. Int J Surg. 2017;40:178–186.
• 14. Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. J Bone Joint Surg (Br). 1995; 77(1):60–3
• 15. Clanton TO, Haytmanek CT, Williams BT, et al. A biomechanical comparison of an open repair and 3 minimally invasive percutaneous Achilles tendon repair techniques during a simulated, progressive rehabilitation protocol. Am J Sports Med 2015;43(8):1957–64
• 16. Carmont MR, Rossi R, Scheffler S, Mei-Dan O, Beaufils P. Percutaneous and mini invasive achilles tendon repair. Sports Medicine, Arthroscopy, rehabilitation, therapy, Technology. 2011;3:28
• 17. Jiang X, Qian S, Chen C, Wu H, Zhi X, Xu D, Lian J, Liu X, Wei S, Xu F. Modified mini-incision "internal splinting" versus percutaneous repair technique of acute Achilles tendon rupture: five year retrospective case-controlled study. Int Orthop. 2021 Aug 13. doi: 10.1007/s00264-021-05185-0
• 18. Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture – Development of an evidence-based treatment protocol. Injury. 2014;45(11), 1782–1790.
• 19. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349–53.
• 20. Klein W, Lang DM, Saleh M. The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendon Achilles. Chir Organi Mov 1991;76:223–8
• 21. Braunstein M, Baumbach SF, Boecker W, Carmont MR, Polzer H. Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc. 2018 Mar;26(3):846-853.
• 22. McCormack R, Bovard J. Early functional rehabilitation or cast immobilisation for the postoperative management of acute Achilles tendon rupture? A systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2015;49:1329–1335
• 23. Kupcha PC, Mackenzie WGS.Percutaneous achilles tendon repair using ring forceps. Am J Orthop (Belle Mead NJ) 2008;37(11):586
• 24. Telleria JJM, Smith JT, Ready LV, Bluman EM. Outcomes of Limited Open Achilles Repair Using Modified Ring Forceps. Orthop J Sports Med. 2018 Sep 13;6(9)
• 25. Majewski M, Schaeren S, Kohlhaas U, Ochsner PE. Postoperative rehabilitation after percutaneous Achilles tendon repair: early functional therapy versus cast immobilization. Disabil Rehabil. 2008; 30(20-22):1726-32.
• 26. Valkering KP, Aufwerber S, Ranuccio F, Lunini E, Edman G, Ackermann PW. Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response: a single-blinded randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2017 Jun;25(6):1807-1816.
• 27. Ozkaya U, Parmaksizoglu AS, Kabukcuoglu Y, Sokucu S, Basilgan S. Open minimally invasive Achilles tendon repair with early rehabilitation: Functional results of 25 consecutive patients. Injury, Int. J. Care Injured. 2009;40: 669–672