Clinical effect of three suture methods on acute Achilles tendon rupture under two types of incisions
Authors: YOU Yong-liang , YANG Wen-fu , WU Xue-jun , CHEN Liang , XUE Huohuo 
Published: July 2023

Abstract
Background
Modified Krackow, Bunnell, and Kessler sutures under different suture incisions can be used to directly suture ruptured Achilles tendons, but different suture techniques have various advantages and disadvantages. This study aimed to discuss the clinical effects of different suture techniques with different incision sizes.
Methods
This study retrospectively recruited and classified 159 patients with acute Achilles tendon injuries into minimally invasive surgery (MIS) and open surgery (OS) following operation incision size. Patients were subdivided into MIS-Krackow, MIS-Bunnell, MIS-Kessler, OS-Krackow, OS-Bunnell, and OS-Kessler. Age, sex, length of stay, creatine kinase levels (CK) pre- and postoperatively, incision length, operation time, intraoperative bleeding, AOFAS ankle-hindfoot scale, ATRS score, and range of ankle dorsalis and plantar flexion were collected and statistically compared, as well as motion, bilateral calf circumference difference, heel-rise repetition ratio, heel-rise height ratio, blood flow velocity in Achilles tendon, and complications.
Results
Length of stay, postoperative CK levels, surgical bleeding, and pain medication dosage demonstrated significant differences between the MIS and OS groups (P < 0.001). Operative time demonstrated significant differences between the MB:OKa, MB:OB, MKs:MKa, MKs:OKa, MKs:OB, MKs:OKs, and OKa:Oks groups (P < 0.05). Incision length demonstrated significant differences between the MB:MKa and MIS:OS groups (P < 0.05). The mean systolic blood flow velocity of the MB:MKa, MB:OKa, MB:OB, MKs:OKa, MKa:OB, MKa:OKs, OKa:OB, and OKa:OKs groups were different at 1 week postoperatively (P < 0.05). MB:MKs, MB:MKa, MB:OKa, MKs:OB, MKa:OKs, OKa:OB, and OKa:OKs groups demonstrated significant differences at 8 weeks postoperatively (P < 0.05). The dorsiflexion range of motion of MIS:OS was significantly different at 6 weeks postoperatively (P < 0.05). AOFAS demonstrated significant differences between the MIS and OS groups, except for the MKs:OKa and MKs:OB groups (P < 0.05). Only the AOFAS of the MB:OKs, MB:OB, MKa:OB, and MKa:OKs groups were significantly different at 24 postoperatively (P < 0.05). All indexes demonstrated no difference at 48 postoperatively (P > 0.05). Complications included Achilles tendon adhesion in 7 cases (1, 3, 1, and 2 cases in the OKa, OKs, OB, and MKs groups, respectively). Nerve injury occurred in two cases (MKa and MB groups, respectively). Incision infection occurred in 6 patients (3, 2, and 1 in the OKa, OB, and OKs groups, respectively). Achilles tendon re-rupture occurred in 7 cases (5 in the MKs group and 2 in the OKs group). The excellent and good rates of MKa, MB, MKs, Oka, OB, and OKs were 92.0%, 100%, 87.0%, 96.3%, 100%, and 93.1% as assessed by Arnerlind-holm, with no significant differences between the six groups.
Conclusions
Both OS and MIS are safe and effective in treating Achilles tendon rupture. Among them, MIS caused less secondary trauma and better ankle ROM and AOFAS scores in the previous period, but this difference was not significant at 24 and 48 weeks of follow-up. Krackow’s operation time was longer and the intensity was higher compared with the three suture methods of the two surgical methods, but the local blood flow rate of the Achilles tendon was significantly worse than Bunnell and Kessler. Additionally, Kessler was easier to operate and had better blood transport than Krackow, but the intensity was poor and the probability of complications was higher than the other two groups. Bunnell has better overall performance, less blood flow impact, and fewer complications, and is recommended as the choice of suture method for percutaneous surgery.