Tension offloading improves cutaneous scar formation in Achilles tendon repair

Abstract

Hypertrophic scar formation and non-healing wounds following Achilles tendon repair arise from poor vascularity to the incisional site or from excess mechanical stress/strain to the incision during the healing process. The embrace® scar therapy dressing is a tension offloading device for incisional scars. This study explored the effects of tension offloading during Achilles scar formation. A healthy 30-year-old male without any medical co-morbidities developed an acute rupture of his left Achilles tendon. The patient underwent open repair 1 week after injury. At post-operative day (POD) 14, the patient started daily tension offloading treatment on the inferior portion of the incision through POD 120. By POD 120, the untreated portion of the Achilles incision appeared hypertrophic and hyperpigmented, while the treated portion of the scar appeared flat with minimal pigmentation changes. The 12-week treatment of tension offloading on an Achilles tendon repair incision significantly improved cosmesis compared to untreated incision.

Keywords: Achilles tendon; embrace; hypertrophic scar; scar; tension offloading; wound healing.

Figure 1

A sagittal view of the MRI of patient’s left Achilles demonstrates an acute, complete, Achilles rupture (circled in red) ~4 cm above the calcaneal insertion.

Figure 2

Intraoperative photograph demonstrating the open surgical technique utilized to repair the patient’s Achilles; initially, the proximal and distal stumps were debrided, controlled using Allis clamps and adequate excursion was noted with intraoperative testing; Krackow stitch was taken medially and laterally at the proximal stump and the distal stump with #2 FiberWire and the two edges of FiberWire were tied; #2 Orthocord was utilized to imbricate and reinforce with a Bunnell suture, followed by interrupted vicryl sutures; finally, the paratenon and subcutaneous tissue were closed in an interrupted fashion with vicryl sutures, while the epidermis was closed with interrupted nylon sutures.

Figure 3

(A) Schematic representation of tension offloading device location and use during post-operative recovery from POD 14 until POD 120; (B) gross images of Achilles tendon repair incision prior to starting (POD 14), during (POD 28) and after completion (POD1 20) of treatment with the tension offloading device to the inferior portion of the incision; the middle panel (POD 28) demonstrates the patient actively utilizing the tension offloading device on the inferior portion of the incision; dotted black line demarcates non-treated scar (above the line) and treated scar (below the line).