Research Article| Volume 62, ISSUE 2, P222-227, March 2023

Download started.


The Efficacy of Posterior Fasciotomy Versus Inserted Vacuum Drainage in Reducing Postoperative Surgical Site Infection in Open Achilles Tendon Repair: A Prospective Cohort Study With Inverse Probability Treatment Weight Propensity Score Analysis


      Posterior crural fasciotomy (PF) may reduce postoperative surgical site infection (SSI) rate compared to inserted vacuum suction drainage (VD) in open Achilles tendon repair surgery. Thus, we aimed to compare the postoperative SSI rate between PF and VD in open Achilles's tendon repair surgery. A prospective, single-centered, nonrandomized controlled study of consecutive adult patients undergoing primary open Achilles tendon repair was performed at tertiary referral hospital between January 2017 and January 2020. Patients received either PF or VD from 2 experienced surgeons. Data were collected on demographic, clinical, and intraoperative characteristics along with postoperative SSI and other outcomes. The primary outcome was SSI rate. Secondary outcomes were Achilles tendon total rupture score, functional foot index, and visual analogue scale. A total of 60 patients were eligible and included in the final analysis (PF group n = 30 and VD group n = 30). Two (6.7%) patients in the PF group and 5 (16.7%) patients in the VD group experience postoperative SSI (crude risk ratio 0.40; 95% confidence interval 0.08, 1.90; p = .228). In inverse-probability-treatment-weighted propensity score analysis, the PF group had a significantly lower SSI rate than the VD group (adjusted risk ratio 0.30; 95% confidence interval 0.01, 0.91; p = .033). Inverse-probability-treatment-weighted propensity score analysis of Achilles tendon total rupture score along with crude analysis of total functional foot index and visual analogue scale were also significantly better in the PF group than the VD group (all p < .05). PF during open Achilles repair was associated with a significant reduction in postoperative SSI infection rate compared to VD.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jarvinen TA
        • Kannus P
        • Maffulli N
        • Khan KM.
        Achilles tendon disorders: etiology and epidemiology.
        Foot Ankle Clin. 2005; 10: 255
        • Movin T
        • Ryberg A
        • McBride DJ
        • Maffulli N.
        Acute rupture of the Achilles tendon.
        Foot Ankle Clin. 2005; 10: 331
        • Jozsa L
        • Kvist M
        • Balint BJ
        • Reffy A
        • Jarvinen M
        • Lehto M
        • Barzo M.
        The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases.
        Am J Sports Med. 1989; 17: 338
        • Willits K
        • Amendola A
        • Bryant D
        • Mohtadi NG
        • Giffin JR
        • Fowler P
        • Kean CO
        • Kirkley A.
        Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation.
        J Bone Joint Surg Am. 2010; 92: 2767
        • Soroceanu A
        • Sidhwa F
        • Aarabi S
        • Kaufman A
        • Glazebrook M.
        Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials.
        J Bone Joint Surg Am. 2012; 94: 2136
        • Zhou K
        • Song L
        • Zhang P
        • Wang C
        • Wang W.
        Surgical versus non-surgical methods for acute Achilles tendon rupture: a meta-analysis of randomized controlled trials.
        J Foot Ankle Surg. 2018; 57: 1191
        • Lantto I
        • Heikkinen J
        • Flinkkila T
        • Ohtonen P
        • Siira P
        • Laine V
        • Leppilahti J.
        A prospective randomized trial comparing surgical and nonsurgical treatments of acute Achilles tendon ruptures.
        Am J Sports Med. 2016; 44: 2406
        • Pajala A
        • Kangas J
        • Ohtonen P
        • Leppilahti J.
        Rerupture and deep infection following treatment of total Achilles tendon rupture.
        J Bone Joint Surg Am. 2002; 84: 2016
        • Scott WN
        • Inglis AE
        • Sculco TP.
        Surgical treatment of reruptures of the tendoachilles following nonsurgical treatment.
        Clin Orthop Relat Res. 1979; 140: 175-177
        • Ademoglu Y
        • Ozerkan F
        • Ada S
        • Bora A
        • Kaplan I
        • Kayalar M
        • Kul F
        Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture.
        J Foot Ankle Surg. 2001; 40: 158
        • Innocenti M
        • Tani M
        • Carulli C
        • Ghezzi S
        • Raspanti A
        • Menichini G.
        Radial forearm flap plus flexor carpi radialis tendon in Achilles tendon reconstruction: surgical technique, functional results, and gait analysis.
        Microsurgery. 2015; 35: 608
        • Saper D
        • Lybrand K
        • Creevy W
        • Li X.
        Using a posterior compartment fasciotomy and paratenon closure in acute Achilles tendon repair.
        Orthopedics. 2016; 39: e790
        • Chiodo CP
        • Den Hartog B.
        Surgical strategies: acute Achilles rupture-open repair.
        Foot Ankle Int. 2008; 29: 114
        • Myerson MS.
        Achilles tendon ruptures.
        Instr Course Lect. 1999; 48: 219
        • Mandelbaum BR
        • Myerson MS
        • Forster R.
        Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation.
        Am J Sports Med. 1995; 23: 392
        • Ozer H
        • Selek HY
        • Harput G
        • Oznur A
        • Baltaci G.
        Achilles tendon open repair augmented with distal turndown tendon flap and posterior crural fasciotomy.
        J Foot Ankle Surg. 2016; 55: 1180
        • Kosins AM
        • Scholz T
        • Cetinkaya M
        • Evans GRD.
        Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis.
        Plast Reconstr Surg. 2013; 132: 443
        • Clifton R
        • Haleem S
        • McKee A
        • Parker MJ.
        Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials.
        Int Orthop. 2008; 32: 723
        • Berrios-Torres SI
        • Umscheid CA
        • Bratzler DW
        • Leas B
        • Stone EC
        • Kelz RR
        • Reinke CE
        • Morgan S
        • Solomkin JS
        • Mazuski JE
        • Dellinger EP
        • Itani KMF
        • Berbari EF
        • Segreti J
        • Parvizi J
        • Blanchard J
        • Allen G
        • Kluytmans J
        • Donlan R
        • Schecter WP
        • Healthcare Infection Control Practices Advisory C
        Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017.
        JAMA Surg. 2017; 152: 784
        • Mangram AJ
        • Horan TC
        • Pearson ML
        • Silver LC
        • Jarvis WR.
        Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee.
        Am J Infect Control. 1999; 27: 97
        • Nilsson-Helander K
        • Thomee R
        • Silbernagel KG
        • Thomee P
        • Faxen E
        • Eriksson BI
        • Karlsson J.
        The Achilles tendon total rupture score (ATRS): development and validation.
        Am J Sports Med. 2007; 35: 421
        • Ganestam A
        • Barfod K
        • Klit J
        • Troelsen A.
        Validity and reliability of the Achilles tendon total rupture score.
        J Foot Ankle Surg. 2013; 52: 736
        • Kearney RS
        • Achten J
        • Lamb SE
        • Parsons N
        • Costa ML.
        The Achilles tendon total rupture score: a study of responsiveness, internal consistency and convergent validity on patients with acute Achilles tendon ruptures.
        Health Qual Life Outcomes. 2012; 10: 24
        • Budiman-Mak E
        • Conrad KJ
        • Mazza J
        • Stuck RM.
        A review of the foot function index and the foot function index - revised.
        J Foot Ankle Res. 2013; 6: 5
        • Bovonsunthonchai S
        • Thong-On S
        • Vachalathiti R
        • Intiravoranont W
        • Suwannarat S
        • Smith R.
        Thai version of the foot function index: a cross-cultural adaptation with reliability and validity evaluation.
        BMC Sports Sci Med Rehabil. 2020; 12: 56
        • Bihel L
        • Reynaud V
        • Givron P
        • Clavelou P
        • Cornut-Chauvinc C
        • Pereira B
        • Thomas E
        • Taithe F
        • Coudeyre E.
        Foot function index: a promising questionnaire for individuals with Charcot-Marie-Tooth disease type 1A.
        Arch Phys Med Rehabil. 2019; 100: 2403
        • Madeley NJ
        • Wing KJ
        • Topliss C
        • Penner MJ
        • Glazebrook MA
        • Younger AS.
        Responsiveness and validity of the SF-36, Ankle osteoarthritis scale, AOFAS ankle hindfoot score, and foot function index in end stage ankle arthritis.
        Foot Ankle Int. 2012; 33: 57
        • SooHoo NF
        • Vyas R
        • Samimi D.
        Responsiveness of the foot function index, AOFAS clinical rating systems, and SF-36 after foot and ankle surgery.
        Foot Ankle Int. 2006; 27: 930
        • Landorf KB.
        Reliability of the foot function index: a report of the AOFAS outcomes committee.
        Foot Ankle Int. 2006; 27: 867
        • SooHoo NF
        • Samimi DB
        • Vyas RM
        • Botzler T.
        Evaluation of the validity of the foot function index in measuring outcomes in patients with foot and ankle disorders.
        Foot Ankle Int. 2006; 27: 38
        • Budiman-Mak E
        • Conrad KJ
        • Roach KE.
        The foot function index: a measure of foot pain and disability.
        J Clin Epidemiol. 1991; 44: 561
        • Repo JP
        • Tukiainen EJ
        • Roine RP
        • Kautiainen H
        • Lindahl J
        • Ilves O
        • Jarvenpaa S
        • Hakkinen A.
        Reliability and validity of the Finnish version of the visual analogue scale foot and ankle (VAS-FA).
        Foot Ankle Surg. 2018; 24: 474
        • Saarinen AJ
        • Uimonen MM
        • Sandelin H
        • Toom A
        • Richter M
        • Repo JP.
        Minimal important change for the visual analogue scale foot and ankle (VAS-FA).
        Foot Ankle Surg. 2021; 27: 196
        • Stuber J
        • Zech S
        • Bay R
        • Qazzaz A
        • Richter M.
        Normative data of the visual analogue scale foot and ankle (VAS FA) for pathological conditions.
        Foot Ankle Surg. 2011; 17: 166
        • Yang X
        • Meng H
        • Quan Q
        • Peng J
        • Lu S
        • Wang A.
        Management of acute Achilles tendon ruptures: a review.
        Bone Joint Res. 2018; 7: 561
        • Singh-Ranger D.
        A simple technique for the retention of a subcuticular suture.
        Surgeon. 2003; 1: 149
        • Smoot EC.
        Method for securing a subcuticular suture with minimal buried knot.
        Plast Reconstr Surg. 1998; 102: 2447
        • La Padula A.
        A new technique to secure an entirely buried subcuticular suture.
        Plast Reconstr Surg. 1995; 95: 423
        • Austin PC.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399
        • Austin PC
        • Stuart EA.
        Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies.
        Stat Med. 2015; 34: 3661
        • GW AAI
        Matching on the estimated propensity score.
        Econometrica. 2016; 84: 781
        • Yang B
        • Liu Y
        • Kan S
        • Zhang D
        • Xu H
        • Liu F
        • Ning G
        • Feng S.
        Outcomes and complications of percutaneous versus open repair of acute Achilles tendon rupture: a meta-analysis.
        Int J Surg. 2017; 40: 178
        • Muller SA
        • Evans CH
        • Heisterbach PE
        • Majewski M.
        The role of the paratenon in Achilles tendon healing: a study in rats.
        Am J Sports Med. 2018; 46: 1214
        • Austin PC
        • Schuster T
        • Platt RW.
        Statistical power in parallel group point exposure studies with time-to-event outcomes: an empirical comparison of the performance of randomized controlled trials and the inverse probability of treatment weighting (IPTW) approach.
        BMC Med Res Methodol. 2015; 15: 87
        • Pirracchio R
        • Resche-Rigon M
        • Chevret S.
        Evaluation of the propensity score methods for estimating marginal odds ratios in case of small sample size.
        BMC Med Res Methodol. 2012; 12: 70