van Maele Margaux, Misselyn Dominique, Metsemakers Willem-Jan, Sermon An, Nijs Stefaan, Hoekstra Harm
KU Leuven - University of Leuven, Faculty of Medicine, B-3000 Leuven, Belgium.
University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium.
Injury. 2018 Oct;49(10):1947-1952. doi: 10.1016/j.injury.2018.08.012. Epub 2018 Aug 17.
Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures.
Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved.
We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant.
The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.
急性跟腱断裂有多种治疗策略，可能会产生深远影响。开放修复术并发症发生率高，而经皮技术再断裂率较高。本研究的目的是评估开放手术修复的临床疗效和经济负担，并为急性跟腱断裂确定一个医学和经济上合理的治疗方案。
回顾性研究2012年6月至2016年12月期间105例采用开放手术治疗的急性跟腱断裂患者。从电子患者数据库中获取所有人口统计学、临床和与医院相关的费用。发放阿基里斯肌腱评分系统（ATRS）问卷以评估功能结局。获得了70.5%的回复率。
我们记录的并发症发生率为40%，分别为腓肠神经感觉减退（14.3%）、伤口愈合延迟（28.6%）、感染（20.9%）和再断裂（4.8%）。外科住院医师作为主刀医生并发症发生率较高（p = 0.042）。总体而言，记录的ATRS功能评分中位数为17（四分位间距6.5 - 39.5）。与再断裂相比，感染患者的人均总医疗费用显著更高（17435欧元对4537欧元，p = 0.013）。手术清创的总成本（n = 6）比再断裂（n = 5）高出约5倍，即108382欧元对22272欧元。感染和再断裂后手术清创的ATRS评分中位数与总体ATRS评分无显著差异，分别为32（四分位间距21 - 63）和28（四分位间距15 - 28）。然而，10分的差异被认为具有临床相关性。
跟腱断裂开放修复的总体功能结局相当不错，但并发症发生率较高，主要是由于伤口问题和感染。虽然确定了几个风险因素，但只有主刀医生这一因素是可以改变的。考虑到与再断裂手术相比，感染情况下手术清创的总成本较高，尽管功能结局相同，我们决定改变临床实践以降低并发症发生率和医疗费用。经皮修复的结局和确切费用将另行探讨。
