Wound complications after achilles tendon repair

Background

Due to the lack of blood supply in this area and the thin soft tissues covering the achilles tendon, wound complications in this area are common after procedures on the achilles tendon, especially if large permanent braided sutures are utilized. Dr. Dowlatshahi is frequently asked to see patients with wound issues after achilles repairs or reconstructions.

Causes

Risk factors are age, diabetes, smoking status, and immunocompromised patients. A breach in sterile technique, or incision breakdown can lead to colonization of the braided suture material and subsequent infection. Clearing infection from this suture material is very difficult, even with strong antibiotics and good wound care.

Symptoms

Continued drainage and swelling, as well as pain and discomfort at the achilles tendon repair site. The incision is often open, with one or more draining sinuses. Repeated bouts of drainage and infection often occur, requiring antibiotic treatment.

Diagnosis

When a wound complication occurs, it is important to assess the soft tissues carefully and understand what the original injury was, and the specifics of how it was treated. If bone anchors are used, the patient must be assessed for signs for bone infection called osteomyelitis. An MRI or CT scan can be helpful.

Treatment

These wounds rarely close completely without surgical intervention. Continued wound care over months with various costly and labor-intensive modalities are most often futile.

Treatment options range from simple wound management to reoperation with removal of all suture material and a meticulous skin closure. On occasion, flaps are utilized to cover and close the soft tissue defect.

This is an example of what a this wound complication can look like:

Prior to reconstruction, a thorough debridement / cleanout is necessary, with removal of all foreign material. Due to the presence of bone infection in this case, the bone anchors also had to be removed.

The following example shows a different patient that developed a bone infection and required an aggressive surgical debridement (cleanout) as well. This image shows the size of the wound which goes down to the calcaneus bone.

The reconstruction involved dissecting a segment of skin and a small island of muscle called a medial sural artery perforator (MSAP) flap.

The flap was then brought to the ankle. The muscle was placed in the hole in the bone to provide blood supply and help clear the infection. The skin was used to cover the soft tissue defect. Since this was a free flap, it required reconnecting the vessels at the ankle under the microscope. This image shows the flap in place. It healed uneventfully and after 6 weeks of IV antibiotics the patient was able to resume activities without restrictions.