Perspective

Tourniquet time linked with repaired Achilles tendon infection

Achilles tendon ruptures treated surgically had a low risk of infection and re-rupture, but these risks were greater in the presence of certain patient and surgical factors, according to study results.

“Achilles tendon repairs are associated with a pretty low risk of infection or re-rupture,” Toufic R. Jildeh, MD, of the Henry Ford Health System, told Orthopedics Today. “However, patients with longer tourniquet times and higher estimated blood loss [EBL] and those who had a history of smoking were found to be at increased risk for surgical site infections [SSIs]. Moreover, patients with longer operative times and tourniquet times were also found to have a higher risk of re-ruptures.”

Among 423 patients who underwent surgical intervention for Achilles tendon ruptures between 2008 and 2014, the infection rate was 2.8% and the re-rupture rate was 1%.

Toufic R. Jildeh, MD
Toufic R. Jildeh

“With regard to infection, we found that those who were current or former smokers had about a 4% to 4.5% increased chance of superficial infections,” Jildeh said at a meeting.

He noted longer tourniquet times and greater EBL led to an increased rate of deep SSI, factors that could be increased by the hypovascular state of the patients’ Achilles tendons.

“The Achilles tendon is natively in a hypovascular state and a tourniquet further increases the risk of tissue hypoxia and inflammation,” Jildeh said. “Although a tourniquet may help surgical exposure, the surgeon must be mindful of these factors.”

Because this tendon is sensitive to variations in blood flow and nutrient delivery, “there can be implications on wound healing, tissue degeneration and healing potential with increased blood loss,” he said.

Although there was a higher re-rupture rate found among patients with longer operative times and longer tourniquet times, Jildeh noted neither of these reached statistical significance.

“There are actually a lot [of factors] surgeons can control, operative time and tourniquet time being some of them. I think both factors can have implications on outcomes,” Jildeh told Orthopedics Today.

According to Jildeh, few studies have been done to analyze operative time and tourniquet time for tendon repairs. However, when he and his colleagues compared their results to the literature on rotator cuff tendons, they found the outcomes were similar.

“The studies conducted on rotator cuff retears have echoed our findings as well in that increased operative times have huge implication on outcomes,” Jildeh said.

“The next step for this would be a prospective study looking at the role of operative times or maybe expanding our retrospective study and seeing if there are other factors that affect infection rates that we may not have initially thought of,” he said.– by Casey Tingle

Disclosure: Jildeh reports no relevant financial disclosures.

Achilles tendon ruptures treated surgically had a low risk of infection and re-rupture, but these risks were greater in the presence of certain patient and surgical factors, according to study results.

“Achilles tendon repairs are associated with a pretty low risk of infection or re-rupture,” Toufic R. Jildeh, MD, of the Henry Ford Health System, told Orthopedics Today. “However, patients with longer tourniquet times and higher estimated blood loss [EBL] and those who had a history of smoking were found to be at increased risk for surgical site infections [SSIs]. Moreover, patients with longer operative times and tourniquet times were also found to have a higher risk of re-ruptures.”

Among 423 patients who underwent surgical intervention for Achilles tendon ruptures between 2008 and 2014, the infection rate was 2.8% and the re-rupture rate was 1%.

Toufic R. Jildeh, MD
Toufic R. Jildeh

“With regard to infection, we found that those who were current or former smokers had about a 4% to 4.5% increased chance of superficial infections,” Jildeh said at a meeting.

He noted longer tourniquet times and greater EBL led to an increased rate of deep SSI, factors that could be increased by the hypovascular state of the patients’ Achilles tendons.

“The Achilles tendon is natively in a hypovascular state and a tourniquet further increases the risk of tissue hypoxia and inflammation,” Jildeh said. “Although a tourniquet may help surgical exposure, the surgeon must be mindful of these factors.”

Because this tendon is sensitive to variations in blood flow and nutrient delivery, “there can be implications on wound healing, tissue degeneration and healing potential with increased blood loss,” he said.

Although there was a higher re-rupture rate found among patients with longer operative times and longer tourniquet times, Jildeh noted neither of these reached statistical significance.

“There are actually a lot [of factors] surgeons can control, operative time and tourniquet time being some of them. I think both factors can have implications on outcomes,” Jildeh told Orthopedics Today.

According to Jildeh, few studies have been done to analyze operative time and tourniquet time for tendon repairs. However, when he and his colleagues compared their results to the literature on rotator cuff tendons, they found the outcomes were similar.

“The studies conducted on rotator cuff retears have echoed our findings as well in that increased operative times have huge implication on outcomes,” Jildeh said.

“The next step for this would be a prospective study looking at the role of operative times or maybe expanding our retrospective study and seeing if there are other factors that affect infection rates that we may not have initially thought of,” he said.– by Casey Tingle

Disclosure: Jildeh reports no relevant financial disclosures.

    Perspective
    Brandon J. Erickson

    Brandon J. Erickson

    The authors should be commended for their study evaluating the risk of infection and re-rupture following Achilles tendon repair. The optimal treatment of Achilles tendon tears is currently debatable. Some advocate for operative repair citing improvements in strength and high-level sporting activities while others recommend non-surgical treatment with accelerated functional rehabilitation citing higher infection rates and wound complications with operative repair. The authors did not attempt to compare operative and nonoperative treatment, but rather looked for potential risk factors for wound complications/infections and re-rupture following operative Achilles repair. One of the more interesting findings was the increased infection (and non-statistically significant increased re-rupture) rate with longer operative times. Several new techniques have emerged to decrease incision size, as well as operative time, through a minimally invasive approach. No studies to date have compared these minimally invasive techniques with standard open approaches. Given the findings of the current study, it seems that using a minimally invasive approach with a faster operative time may mitigate some of the most feared complications following Achilles operative repair, allowing surgeons to fix Achilles tears and help athletes regain their preoperative function without the serious surgical complications.

    • Brandon J. Erickson, MD
    • Sports medicine and shoulder, Rothman Orthopaedic Institute, New York

    Disclosures: Erickson reports no relevant financial disclosures.