Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Christopher P. Chiodo, MD*,
Brigham and Women's Hospital, Boston, Massachusetts
Posted May 2009
Surgical repair of an acute Achilles tendon rupture is a
commonly performed orthopaedic procedure. Relatively straightforward, this
procedure not only falls within the domain of the sports-medicine and foot-and-ankle
subspecialists but is commonly performed by general orthopaedists as well.
Still, many questions about Achilles tendon repair remain
unanswered. Should it be performed in an open or a minimally invasive fashion? Which
suture construct is best? When should protected weight-bearing be allowed postoperatively?
Does a primary repair need to be augmented?
The latter question is the focus of the present
investigation by Pajala et al. Some might argue that this is an irrelevant
issue and that there is no need to augment a primary Achilles tendon repair; however,
more than one center has reported the use of augmentation in primary repairs1-3.
The issue is important because rerupture and decreased strength are known
complications of Achilles repair.
The current authors answer this question and present Level-I
evidence demonstrating that augmentation of primary Achilles tendon repairs is
not necessary. In their study, sixty patients were prospectively randomized to
undergo primary repair with or without augmentation with use of a gastrocnemius
aponeurosis turn-down flap. While the mean operative time was longer in the
augmentation group, there were no significant differences in clinical outcome
between groups.
For the practicing orthopaedist, this study offers useful
data that should readily guide clinical decision-making. By avoiding an
unnecessary step during repair, operative time is saved. Is surgical morbidity avoided?
While not statistically significant, it should be noted that deep infection
developed in the wounds of two patients in the augmented repair group as
compared with no infection in the primary repair group. In theory, it could be
that the added bulk of the augmentation predisposes to wound problems. Greater
statistical power would ultimately be necessary to prove or disprove this
theory.
In conclusion, Pajala et al. are to be commended for
conducting a straightforward, well-designed study that confirms that
augmentation of a primary Achilles tendon repair is not necessary.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
1. Jessing P, Hansen E. Surgical treatment of 102 tendo achillis ruptures--suture or tenontoplasty? Acta Chir Scand. 1975;141:370-7.
2. Nyyssönen T, Saarikoski H, Kaukonen JP, Lüthje P, Hakovirta H. Simple end-to-end suture versus augmented repair in acute Achilles tendon ruptures: a retrospective comparison in 98 patients. Acta Orthop Scand. 2003;74:206-8.
3. Zell RA, Santoro VM. Augmented repair of acute Achilles tendon ruptures. Foot Ankle Int. 2000;21:469-74.
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