Hongtao Xiong, Department of Hand ＆ Vascular surgery, Shenzhen First Hospital, the Second Clinical Medical College of Jinan University, Guangdong, Shenzhen 518020, China

Yuzhou Liu, Department of Hand surgery, Huashan Hospital，Affiliated hospital of Fudan University, Shanghai 200040,China

Yongqing Zhuang, Department of Hand ＆ Vascular surgery, Shenzhen First Hospital, the Second Clinical Medical College of Jinan University, Guangdong, Shenzhen 518020, China

Jie Lao, Department of Hand surgery, Huashan Hospital，Affiliated hospital of Fudan University, Shanghai 200040,China

Chunling Chen, Department of Hand ＆ Vascular surgery, Shenzhen First Hospital, the Second Clinical Medical College of Jinan University, Guangdong, Shenzhen 518020, China

Abstract
Background To introduce a new surgical approach for Achilles tendon repair and analyze its clinical effect and postoperative complications compared with the traditional long incision approach. Methods A retrospective control study of 43 patients treated with Achilles tendon rupture using two different approaches carried out. The conventional approach: one continuous longitudinal incision, 1cm medial from the central posterior ankle joint. The modified approach: one short S shape incision across the posterior part of the ankle and 2 pairs of tiny incisions at the proximal edges of Achilles tendon. The Arner-Lindholm score was used for ankle function evaluation and complications were summarized. Results In the conventional group (25 patients), there were 4 cases with local skin necrosis. Achilles tendon rupture occurred again in one patient 2 month after surgery. No cutaneous nerve injury occurred. The total incidence rate of complication was 20%. In the modified group (19 patients), one patient had sural nerve injury. No wound dehiscence and re-rupture of Achilles tendon occurred in all the cases. The total incidence rate of complication was 5.3%. There were significant differences between the two groups in the incidence of postoperative complications (P < 0.05). The excellent and good rates of the ankle joint function in the modified group were statistically higher than those in the conventional group (P < 0.05).Conclusion The modified surgical approach for Achilles tendon repair was recommended. With this approach fewer complications and better functional recovery could be achieved.

Keywords
operative approach; Achilles tendon rupture; postoperative complication; curative effect

Cite this paper
Hongtao Xiong, Yuzhou Liu, Yongqing Zhuang, Jie Lao, Chunling Chen, A new approach for surgical treatment of acute closed Achilles tendon rupture -- a retrospective clinical study , SCIREA Journal of Clinical Medicine. Volume 4, Issue 6, December 2019 | PP. 289-303.

References

[ 1 ]	Ahn JH, Choy WS. Tendon adhesion after percutaneous repair of the Achilles tendon: a case report. J Foot Ankle Surg. 2011; 50: 93–95. doi: 10.1053/j.jfas.2010.07.008.
[ 2 ]	Aibinder WR, Patel A, Arnouk J, et al. The rate of sural nerve violation using the Achillon device: a cadaveric study. Foot Ankle Int. 2013; 34(6): 870–875. doi: 10.1177/1071100712473097.
[ 3 ]	Aktas S，Kocaoglu B. Open versus minimal invasive repair with Achillon device. Foot Ankle Int. 2009; 30(5): 391–397．doi: 10.3113/FAI.2009.0391.
[ 4 ]	Bae SH, Lee HS, Seo SG, Kim SW, Gwak HC, Bae SY. Debridement and Functional Rehabilitation for Achilles Tendon Infection Following Tendon Repair. J Bone Joint Surg Am. 2016; 98(14): 1161-1167. doi: 10.2106/JBJS.15.01117.
[ 5 ]	Bertelli R, Gaiani L, Palmonari M. Neglected rupture of the Achilles tendon treated with a percutaneous technique. Foot Ankle Surg. 2009; 15: 169–173. doi: 10.1016/j.fas.2008.12.003.
[ 6 ]	Bhattacharyya M，Gerber B. Mini- invasive surgical repair of the Achiles tendon：does it reduce post-operative morbidity? Int orthop. 2009; 33(1): 151-156. doi: 10.1007/s00264-008-0564-5.
[ 7 ]	Carmont MR, Maffulli N. Modified percutaneous repair of ruptured Achilles tendon. Knee Surg Sports Traumatol Arthrosc. 2008; 16: 199–203. doi: 10.1007/s00167-007-0411-z.
[ 8 ]	Carmont MR, Roberto R, Scheffler S, Dan OM, Beaufils P. Percutaneous & Mini Invasive Achilles tendon repair. Sports Med Arthrosc Rehabil Ther Technol. 2011; 3(1): 1-9. doi: 10.1186/1758-2555-3-28.
[ 9 ]	Chiodo CP, Glazebrook M, Bluman EM , et al. Diagnosis and treatment of acute Achilles tendon rupture. The Journal of the American Academy of Orthopaedic Surgeons. 2010; 18(8): 503–510. PMID:20675643.
[ 10 ]	Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med. 2005; 33(9): 1369–1379. doi:10.1177/0363546504271501
[ 11 ]	Davies MS, Solan M. Minimal incision techniques for acute Achilles repair. Foot Ankle Clin. 2009; 14: 685–697. doi: 10.1016/j.fcl.2009.07.006.
[ 12 ]	Eastwood DM, Irgau I, Atkins RM. The distal course of the sural nerve and its significance for incisions around the lateral hindfoot. Foot Ankle. 1992; 13: 199–202. PMID: 1634152.
[ 13 ]	Elliot RR, Calder JD. Percutaneous and mini open repair of acute Achilles tendon rupture. Foot Ankle Clin. 2007; 12: 573–582. doi:10.1016/j.fcl.2007.07.002.
[ 14 ]	Garrick JG. Does accelerated functional rehabilitation after surgery improve outcomes in patients with acute achilles tendon ruptures? Clin J Sport Med. 2012; 22: 379–380. doi: 10.1097/JSM.0b013e3182603905.
[ 15 ]	Haji A, Sahai A, Symes A, Vyas JK. Percutaneous versus open tendon Achilles repair. Foot Ankle Int. 2004; 25(4): 215–218. PMID:15132928.
[ 16 ]	Healy B, Beasley R, Weatherall M. Venous thromboembolism following prolonged cast immobilisation for injury of the tendo Achillis. J Bone Joint Surg. 2010; 92: 646–650. doi: 10.1302/0301-620X.92B5.23241.
[ 17 ]	Henriquez H, Muñoz R, Carcuro G, Bastias C. Is percutaneous repair better than open repair in acute Achilles tendon rupture[J]. Clin Orthop Relat Res. 2012; 470(4): 998-1003. doi: 10.1007/s11999-011-1830-1.
[ 18 ]	Kakiuchi M. A combined open and percutaneous technique for repair of tendon Achilles. Comparison with open repair. J Bone Joint Surg Br. 1995; 77(1): 60–63. PMID: 7822398.
[ 19 ]	Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures: A meta-analysis of randomized, controlled trails [J]. Bone Joint Surg Am. 2005; 87(10): 2202-2210. doi:10.2106/JBJS.D.03049.
[ 20 ]	Knobe M, Gradl G, Klos K, et al. Is percutaneous suturing superior to open fibrin gluing in acute Achilles tendon rupture? Int Orthop. 2015; 39: 535–542. doi: 10.1007/s00264-014-2615-4.
[ 21 ]	Lansdaal JR, Goslings JC, Reichart M, et al. The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional after treatment. Injury. 2007; 38(7): 839–844. doi: 10.1016/j.injury.2006.12.010.
[ 22 ]	Longo UG, Ronga M, Maffulli N. Acute ruptures of the achilles tendon. Sports Med Arthrosc. 2009; 17:127–138. doi: 10.1097/JSA.0b013e3181a3d767.
[ 23 ]	Łukas Kołodziej, Andrzej Bohatyrewicz, Justyna Kromuszczyńska, Jarosław Jezierski, Maciej Biedroń. Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study—preliminary report. Int Orthop. 2013; 37: 625–629. doi: 10.1007/s00264-012-1737-9.
[ 24 ]	Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res. 1977; 128: 247–255. PMID: 340096.
[ 25 ]	Maffulli N, Longo UG, Spiezia F, Denaro V. Minimally invasive surgery for Achilles tendon pathologies. OAJSM. 2010; 1: 95–103. PMID: 24198547.
[ 26 ]	McMahon SE, Smith TO, Hing CB. A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot Ankle Surg. 2011; 17(4): 211–217. doi: 10.1016/j.fas.2010.11.001.
[ 27 ]	Metz R, van der Heijden GJ, Verleisdonk EJ, Kolfschoten N, Verhofstad MH, van der Werken C. Effect of complications after minimally invasive surgical repair of acute Achilles tendon ruptures: report on 211 cases. Am J Sports Med. 2011; 39(4): 820–824. doi: 10.1177/0363546510392012.
[ 28 ]	Molloy A, Wood EV. Complications of the treatment of Achilles tendon ruptures. Foot Ankle Clin. 2009; 14:745–59. doi: 10.1016/j.fcl.2009.07.004.
[ 29 ]	Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI. High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study. Knee Surg Sports Traumatol Arthrosc. 2009; 17: 1234–1238. doi: 10.1007/s00167-009-0727-y.
[ 30 ]	Olsson N, Nilsson-Helander K, Karlsson J, et al. Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1385–1393. doi: 10.1007/s00167-011-1511-3.
[ 31 ]	Saxena A, Maffulli N, Nguyen A, Li A. Wound complications from surgeries pertaining to the Achilles tendon: an analysis of 219 surgeries. J Am Podiatr Med Assoc. 2008; 98: 95–101. PMID:18347116.
[ 32 ]	Solomon LB, Ferris L, Tedman R, Henneberg M. Surgical anatomy of the sural and superficial fibular nerves with an emphasis on the approach to the lateral malleolus. J Anat. 2001; 199: 717–723. PMID:11787825.
[ 33 ]	van der Eng DM, Schepers T, Goslings JC, Schep NW. Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis. J Foot Ankle Surg. 2013; 52: 622–628. doi: 10.1053/j.jfas.2013.03.027.
[ 34 ]	Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int. 2000; 21: 475–477. doi:10.1177/107110070002100604.
[ 35 ]	Aibinder WR, Patel A, Arnouk J, El-Gendi H, Korshunov Y, Mitgang J, et al. The rate of sural nerve violation using the Achillon device: a cadaveric study. Foot Ankle Int. 2013;34(6):870–875. doi: 10.1177/1071100712473097.