Wound Dehiscence After Achilles Tendon Trauma and Repair: Treatment With Ultraportable Negative Pressure Wound Therapy and Compression Therapy

The Achilles tendon originates from the confluence of 2 powerful muscles—the soleus and the gastrocnemius. Achilles tendon rupture is a common injury, especially in males between age 30 years and 40 years, with male-to-female injury ratios ranging from 2:1 to 12:1.¹ Most instances of Achilles tendon rupture occur during athletic activities (75%), particularly activities that involve a jumping movement.² Traumatic injury, such as violent dorsiflexion of the foot after a fall from a height, represents another potential mechanism of tendon rupture.¹ Although most ruptures occur after an extreme strain of pathologic tendons, degenerative changes can also be observed in athletes who participate in endurance sports or in persons who participate in athletic activities only occasionally.² Additional causative factors for tendon rupture include increased body weight and oral corticosteroid and fluoroquinolone antibiotic use.^3,4

Surgical repair poses the risk of re-rupture, deep infection, skin necrosis, deep vein thrombosis, and pulmonary embolism. Superficial infection, delayed wound healing, hematoma, scar sensitivity, and suture granuloma have been reported as minor complications.⁵ General skin healing complication rates of 8% to 14% and deep wound infection rates of 1% to 2% have been reported after surgical repair of Achilles tendon rupture.^6,7 Poor vascularity of this anatomic segment and the thin surrounding soft tissue are the main reasons for postoperative complications and make the wound healing process particularly challenging.

The present case series describes 9 patients who underwent surgical repair of Achilles tendon rupture and subsequently experienced postoperative dehiscence that was treated with ultraportable negative pressure wound therapy (NPWT) and compression bandaging.

Records from the Wound Healing Research Unit at the University of Pisa School of Medicine, Pisa, Italy were reviewed to identify all patients who underwent wound management for dehiscence following surgical repair of the Achilles tendon between January 2014 and January 2018. The diagnosis of postoperative dehiscence was made clinically according to international guidelines.⁸ Patient demographics, wound size at first and last visit, number of visits, and previous treatment data were extracted.

Signs of critical wound colonization were present to a various extent in all patients at the first visit. Management included irrigation with an antiseptic solution, followed by sterile isotonic saline. Surgical debridement of devitalized soft tissue was performed in all patients at baseline. Three patients also underwent partial debridement of the infected tendon, taking care to preserve its continuity. After surgical debridement, an antimicrobial silver dressing (Kerracel Ag; 3M Health Care) was applied in 7 of 9 cases to help control the bacterial load, absorption, and retention of exudate as well as to reduce skin maceration. The silver dressing was discontinued after 1 week. Use of an ultraportable NPWT system (SNAP Therapy System; 3M Health Care) was started for exudate removal and granulation tissue formation across all wounds⁹; risk factors for a protracted healing process were present such as diabetes, obesity, and hypertension. The amount of negative pressure delivered via ultraportable NPWT was −125 mm Hg. Dressing changes were performed twice weekly.

When possible, in patients with an ankle-brachial index (ABI) greater than 0.8, a multilayer, multicomponent compression system (Coban 2; 3M Health Care) was used to achieve sub-bandage pressure greater than 30 mm Hg. Bandages were applied using a spiral technique with a 50% overlap between adjacent layers and provided coverage from the base of the toes to just below the tibial plateau. Treatment response was evaluated using a wound imaging system based on digital acquisition (Silhouette Star; Aranz Medical) at 2-week and 4-week intervals, for a total of 12 weeks. The Dermatology Life Quality Index (DLQI) was used at baseline and again at the end of observation to score patient satisfaction.¹⁰

Nine patients presented to the authors’ department for treatment of wound complications after Achilles tendon surgery between January 2014 and January 2018. The demographic and clinical details are summarized in the Table. The mean age was 69.66 years (range, 47–83 years). All patients were male. Three patients had type 2 diabetes controlled by therapy. Only 1 patient had sustained primary rupture during sports activities; in the remaining 8 patients, tendon injury was the result of household accidents. The average wound area at baseline was 9.95 cm² (range, 3.4–21.1 cm²). All patients had suboptimal responses to previous therapies, such as generic hydrofiber, polyurethane foam, hydrocolloid, and hydrogel.

Overall, 6 of 9 patients achieved complete wound closure with a mean wound healing time of 18 weeks. The 3 remaining patients achieved a mean 90% wound closure rate at the end of the 24-week study period. No side effects were observed during treatment with NPWT. All patients indicated a high level of satisfaction and comfort according to the DLQI assessment, with a substantial reduction in mean score from 26.4 at baseline to 6.8 at the end of the study.

The following 3 representative cases demonstrate the results and outcomes of this series.

Case 1
A 56-year-old male with a medical history of hypertension, obesity, and type 2 diabetes presented to the wound clinic for wound dehiscence resulting from surgical repair of right Achilles tendon rupture (Figure 1). Previously, wound dehiscence had been managed using different dressings, including silver sulfadiazine cream, alginate dressing, and hydrocolloid dressing with collagen, with poor improvement. During the baseline visit, the authors decided to initiate a treatment protocol consisting of an antimicrobial silver dressing for 1 week, followed by use of ultraportable NPWT and compression bandaging. Wound size decreased from 9.8 cm² to 0.4 cm² in 12 weeks, and the patient achieved a substantial improvement in DLQI score, from 26 at baseline to 9 at 12 weeks.

Case 2
A 75-year-old male with a medical history of type 2 diabetes and hypertension was referred by the orthopedic team at a different institution to the wound clinic for management of wound dehiscence in the left Achilles tendon (Figure 2). The patient had previously undergone surgical repair of the tendon after minor trauma and subsequently experienced surgical site infection and wound dehiscence. During consultation at the wound clinic, the patient received local treatment with an antimicrobial silver dressing that was left in place for 1 week, after which he received 5 weeks of treatment with ultraportable NPWT and compression bandaging. Wound closure was achieved, and the patient reported a reduced DLQI score from 24 at baseline to 6 at the end of treatment.

Case 3
A 47-year-old male with no comorbidities presented to the wound clinic for wound dehiscence resulting from surgical repair following Achilles tendon trauma. The wound had previously been managed with different local dressings, including silver sulfadiazine cream, generic hydrofiber dressing, and cadexomer iodine dressing (Figure 3). The patient underwent treatment with a silver dressing for 1 week, followed by management with ultraportable NPWT and compression bandaging, which resulted in wound closure after 6 weeks. The patient continued activities of daily living using the ultraportable NPWT, and the DLQI score decreased substantially, from 24 at baseline to 4 at the end of treatment.

Achilles tendon repairs are associated with a high rate of wound healing complications and surgical site morbidity, resulting in a protracted healing process and limiting the clinical outcome by impairing daily life activities. Current treatment options for postoperative dehiscence of the Achilles tendon include advanced wound dressings and NPWT. Of the 9 patients in the present study who were treated with ultraportable NPWT and compression bandaging, complete healing was achieved in 6 patients and 75% wound closure was achieved in 3 patients.

The current study consisted of 9 male patients, 4 of whom had diabetes. These demographic data do not reflect the more diverse patient populations reported in the literature. Previous studies identified female sex, tobacco use, steroid use, and diabetes as significant risk factors for wound complications after Achilles tendon repair.¹¹

The use of NPWT in the management of postoperative Achilles tendon wounds has been previously reported. In 3 patients with soft-tissue defects over the Achilles tendon with exposed tendon, Repta et al¹² successfully used NPWT to prepare the wound bed for placement of a split-thickness skin graft and in the postoperative period as a dressing for the graft. In the case of a 66-year-old male who presented with an open wound with signs of local infection 11 weeks after tendon reconstruction, Kelm et al¹³ used NPWT and broad-spectrum systemic antibiotics for wound preconditioning during a 3-week hospitalization and later to optimize the skin graft transplant healing process. Mosser et al¹⁴ reported on the use of NPWT in the management of late deep infections after open Achilles tendon reconstruction in 6 patients. Kollrack and Möllenhoff¹⁵ treated 5 patients with deep infection and exposed Achilles tendon after reconstruction, and they found NPWT to be the method of choice for wound healing complications in this delicate area. In the current preliminary case series, patients were treated with only a topical regimen; systemic therapy was not used.

In the current case series, the run-in period in which topical antimicrobial dressing was used was effective in controlling bacterial burden before starting NPWT. Patient satisfaction regarding the medical device and its portability was very high. From the perspective of a health care professional, the main aspects outlined were promoting granulation tissue formation and achieving complete wound healing with NPWT. In the authors’ opinion, use of compression therapy and NPWT was quite important, and no serious drawbacks occurred with this therapeutic approach.

Currently, compression therapy is the first-line treatment in managing leg ulcers,¹⁶ and poor adherence to compression therapy is independently correlated with worse healing rates.¹⁷ When applying a compression bandage, clinicians must consider the Laplace law, which demonstrates the relationship between the pressure exerted on the leg and the parameters involved in creating that pressure. The amount of pressure, number of layers, different components, and elastic properties are the essential characteristics of compression bandages. Different compression stockings, compression bandages, and various compression bandage systems are commercially available.¹⁸ Multicomponent compression systems have been shown to be more effective than single-component compression, and high compression is more effective than lower compression.¹⁹

Not all patients with leg ulcers will benefit from compression therapy, however. High subbandage pressure in patients with peripheral arterial disease could reduce tissue perfusion and lead to further ulceration or even amputation. For this reason, a careful patient history, palpation of peripheral pulses, assessment of ABI, and ultrasound study are required when considering this therapeutic option.²⁰ In particular, an ABI greater than 0.9 indicates that high compression can be used; if ABI results are borderline (>0.6 to 0.8), compression must be applied only by highly skilled staff. An ABI less than 0.5 indicates possibly severe ischemia; compression should be delayed in such patients.

Although compression therapy is an accepted treatment in the healing of venous ulcers, no data are available regarding its effectiveness in the management of postoperative wounds after Achilles tendon repair. In the patients reported in the current study, when possible (ie, ABI >0.8), multilayer, multicomponent compression bandages were applied, which the authors found to be easier to use than the NPWT system.

Limitations exist for this study. This retrospective case series reported data from a small subset of less diverse patients than those evaluated in previously published studies. Because of the lack of published evidence in the use of compression therapy in postoperative wounds of the Achilles tendon, it was not possible to directly compare the results of this study to other patient populations. Larger, randomized controlled studies are necessary to fully assess the potential clinical benefit of NPWT and compression therapy in the management of postoperative wounds of the Achilles tendon.

Achilles tendon repair is associated with a high rate of wound healing complications. In this 9-patient retrospective case series, ultraportable NPWT was found to be a valuable tool in the management of wounds with critical local vascularity. Despite the lack of therapeutic evidence in the published literature, in the current study the addition of compression therapy showed significant effectiveness in healing Achilles tendon ulcers in this patient population. Several types of compression devices are available, and the particular product chosen should be individualized according to patient comorbidities and adherence as well as always applied by a skilled nurse or physician.

Authors: Giulia Davini, RN¹; Valentina Dini, MD, PhD¹; Agata Janowska, MD¹; Michela Macchia, RN¹; Bruno Gualtieri, MD²; Giammarco Granieri, MD¹; and Marco Romanelli, MD, PhD¹

Affiliations: ¹Dermatology Unit, University of Pisa School of Medicine and Surgery, Pisa, Italy; ²Dermatology Unit, Venezia Hospital, Venezia, Italy

Disclosure: The authors disclose no financial or other conflicts of interest.

Correspondence: Marco Romanelli, MD, PhD, Professor and Chairman, University of Pisa, Department of Dermatology, Via Roma, 67, Pisa, Italy 56126; m.romanelli@med.unipi.it, romanellimarco60@gmail.com