Wednesday, March 19, 2008

We mock what we don't understand.

Here is an article I read about the surgical technique of repairing the Achilles tendon.

The patient is placed in the prone position with both prepped feet dangling from the end of the table. By placing the table in Trendelenburg, the feet receive less blood flow. An 8-cm to 10-cm longitudinal incision is made just medial to the Achilles tendon. A posterior lateral incision would place the sural nerve at risk and a mid-posterior incision can result in suture interference from the tendon repair site. After dissecting through the subcutaneous tissues, the paratenon is cut longitudinally with Mayo scissors. As the ruptured ends often have a "mop-end" appearance, some surgeons will wait one week before repair in order to allow the ends to better consolidate. After juxtaposing the ends, the tendon is sewn together with non-absorbable suture via a Krackow or Bunnell stitch. Prior to tying the suture ends, the tendon's dynamic resting tension is optimized by comparing it with the control side. A circumferential stitch is used to further strengthen the repair site. After closing the paratenon, the plantaris fascia can be fanned out over the repair site to help prevent adhesions with the undersurface of the skin. The subcutaneous tissue is then approximated with absorbable suture and the skin sewn together in a nylon mattress fashion. A fasciotomy of the deep posterior compartment can facilitate closure in cases with excessive skin tension. This allows for improved closure of the paratenon as well.

Despite the resurgence of the conservative camp in the 1970s, surgery has been the first choice of treatment for Achilles tendon ruptures in young fit individuals since the late 1980s. Advances in surgical techniques and new postoperative rehabilitation protocols have resulted in studies showing the advantages of direct tendon repair. With conservative treatment, extensive scarring often fills the gap between the torn tendons. This leads to a lengthened tendon, which, in turn, leads to decreased push-off strength. In separate studies, Helgeland and Inglis and colleagues showed that surgical treatment of Achilles tendon rupture resulted in increased strength. Cetti and colleagues and Haggemark independently showed that direct repair resulted in less calf atrophy when compared with non-surgical treatment. Mendelbaum and colleagues showed that those undergoing direct repair lost only 2.6% of their strength when undergoing isokinetic testing and that 92% of athletes were able to return to their respective sports at a similar level at 6 months postoperatively. Cetti and colleagues also showed a higher number of patients returning to their pre-injury athletic level. In addition, surgical repair appears to significantly increase the strength in those suffering re-ruptures. Those treated surgically for the second time increased their level of strength by 85% compared with a 51% strength gain in those treated conservatively.

Perhaps the most well known benefit of surgical repair is the decreased re-rupture rate. Despite favoring nonsurgical treatment, Nistor noted that those treated conservatively had an 8% re-rupture rate while those treated surgically had a 4% rate. Recent studies show an even greater difference. Cetti and colleagues reported re-rupture rates of 1.4% 13.4% for surgical and conservative repair, respectively. In a meta-analysis by Kellam and coworkers, re-rupture rates were found to be 1% and 18% for surgical and conservative repair, respectively. Even more impressive is a study by Inglis and colleagues who reported that none of the 44 patients receiving direct repair re-ruptured, whereas 9 of 24 patients treated nonsurgically did re-rupture.

In contrast to Nistor's 1981 study, more recent studies show an increased complication rate in those treated conservatively. One prospective randomized study reported complication rates of 11.8% in patients treated surgically vs 18% for those treated nonsurgically; 96.6% of the complications in the surgical group were considered minor. Leppilehti and coworkers noted that complications related to surgery did not significantly influence the long term outcome as most of them were minor wound healing problems which eventually healed.

Increased operative treatment also leads to more experience in treating complications effectively. For example, it is now shown that physical therapy can overcome many of the problems associated with adhesions between the repair site and the skin. Moreover, the vast majority of superficial wound infections can be treated effectively with limited weight bearing, oral antibiotics, and silver sulfadiazine (Silvadene). Once the tissue granulates, the wound can simply be treated with wet to dry dressing changes; only in rare circumstances is a local or a free flap necessary.

Those favoring surgical treatment also point out the relatively uncomplicated nature of the procedure. There is no evidence showing that primary augmentation is more effective than simple end-to-end repair in acute tears. Therefore, more extensive procedures using tendon transfers, flaps, or mesh are best left for use with delayed tears, in which the repair will be under tension due to the chronically retracted ends.

1 comment:

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