Delayed Wound Healing After Achilles Tendon Suture: An Arthroscopic Solution

Beijing, China:

Delayed wound healing after Achilles tendon suture will hinder the patient's recovery and affect quality of life. If conservative treatment cannot be adopted, the conventional treatment is to keep the wound open and perform daily irrigation and routine flushing, but this approach leaves a larger wound that takes longer to heal and increases the difficulty of postoperative care.

Hong-yu Chen et al pioneered the use of arthroscopy to treat delayed wound healing after Achilles tendon suture and the results have been satisfactory.

Indications-

(1) The diagnostic criteria for delayed wound healing after Achilles tendon suture are met, namely the presence of skin necrosis, wound nonunion, or delayed wound healing.

(2) The expected healing time of a regular wound is >2 weeks with regular dressing changes.

Contraindications-

(1) Abnormal body temperature (underarm temperature >37.5 C)

(2) Abnormal coagulation function (platelets less than 50 x10/L)

(3) Presence of other diseases; inability to tolerate surgery

(4) If the expected healing time of wounds with regular dressing changes is <2 weeks

Arthroscopy Technique and Postoperative Management

The unhealed part of the original incision (original defect) is selected as the portal to insert the shaver, and the other portal (new portal) for inserting the camera is usually selected at the top of the original incision. This method ensures that the 2 ports are as far away from each other as possible, covers all the suture areas of the Achilles tendon from the first operation, and allows full exploration of the surgical area.

First, the Achilles tendon and surrounding tissues are explored to identify lesions, which includes inflammatory tissues, infected tissues under the skin or around the Achilles tendon, and necrotic tendons. The shaver is then used to remove these lesions.

Next, all the weak areas of the Achilles tendon need to be identified. In their experience, most of the weak areas will have healed, but some cavities may still exist. These cavities of Achilles tendon wounds need to be cleaned by shaver. If foreign bodies (nonabsorbable sutures) are found, they should be removed with nucleus pulposus forceps, which can be inserted from the original defect. If necessary, another portal can be established at the distal end of the scar, so that the distal area of the Achilles tendon can also be accessed by surgery.

Finally, the subcutaneous tissue is processed. The planer is used to remove the inflamed tissue and scar tissue. Skin tissue that has lost bioactivity around the wound also needs to be cut off, and the skin edge of the wound should be trimmed neatly. Primary suturing of the wounds is performed. Roll gauze pads are placed on both sides of the Achilles tendon incision, and a pressure bandage is applied to the surgical area.

If the blood circulation around the wound is poor and slow to heal, or infection is prone to occur, short-term preventive antibiotics can be used after the operation, and a short leg plaster can be used to fix the foot in natural plantar flexion for 2 weeks. Sutures can be removed 2 to 3 weeks after surgery.

Advantages

(1) No requirement for the wound to be open postoperatively for multiple irrigations

(2) Improved visibility of the surgical field

(3) Smaller incisions compared with traditional treatment

(4) Reduced need for postoperative antibiotics

(5) Rehabilitation exercises may be resumed quickly

Limitations

(1) A minor local procedure may be needed at a later stage if a foreign body has not been removed completely.

(2) The cost of this technique is higher than conventional open surgery.

Further reading:

Delayed Wound Healing After Achilles Tendon Suture: An Arthroscopic Solution

Hong-yu Chen, Ying-fang Ao, and Yu-ping Yang.

Arthroscopy Techniques, Vol 11, No 3 (March), 2022: pp e397-e402

https://doi.org/10.1016/j.eats.2021.11.007