The Incision Decision

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To cut, or not to cut?  To repair, or to let heal? To rehab without fixing? To live with imperfect parts? Each of these questions is faced every day by surgeons and their patients. Here are a few decisions about incisions. 

1) The Achilles Rupture. To repair or not? Left unrepaired, most people heal over four months. The healed tendon is usually longer than normal (since the ends were not sewn together) and lacks the same power as it had pre-injury, but is good enough for most people. The traditional surgical repair involves an open incision.  The complications are relatively high, with scarring and infection being the worst. Yet repaired, the tendons heal at their normal length and with more power if a careful rehab program is followed. Here the decision is a bit easier, because the open technique can be replaced by a percutaneous repair technique—where no open incision is made, but sutures are passed through the skin and the tendon is cinched together—and it works just as well as the open technique, without the risks. For the Achilles tendon rupture, percutaneous repair wins. 

2) The ACL Rupture. To reconstruct or not? Interestingly, some people have ACL-independent knees. This means that even without a normal ACL, they do not develop instability. Other times the ACL heals on its own to the other central ligament (called the PCL) and provides some of the necessary stability. In young athletes with traumatic ruptures, it usually doesn’t heal. This often leads to secondary injuries, such as meniscus tears, over time. Even reconstructed, there is a long-term arthritis risk of 50% and a replaced ligament failure rate of 30% in young people.   

Here, the decision is personal. If the knee is fairly stable, with no other injuries —such as cartilage or meniscus tears—there is a role for non-operative care, possibly augmented by stem cell injections to stimulate whatever healing can occur. In unstable athletic knees, an anatomic reconstruction is best. 

3) The Meniscus Tear. In young people, a torn meniscus loses the force distribution characteristics, leading to arthritis. These tears should almost always be repaired if possible. The old thinking—that only meniscus tears with peripheral blood supplies can be sewn back together—has been revised. Today, using newer techniques, we repair nearly all meniscus tears that have healthy tissue (augmented by collagen scaffolds when tissue is missing). We also add stem cells and growth factors to stimulate healing.   

In older people, however, the decision is more difficult. Many have asymptomatic tears. Removing tears in arthritic joints has not led to consistent benefits unless there is mechanical catching due to the tissue. What is now possible (though not widespread) is to replace the torn meniscus with donor tissue. We do this even in older, active athletes, to delay or avoid knee replacement. But each of these decisions depends on the skill and experience of the surgeon and the attitude of the patient. 

4) The Torn Rotator Cuff. New cuff tears present with weakness and pain in the shoulder. They are now easily repaired with arthroscopic techniques. That decision is fairly clear. But which tears to repair and which to simply rehab with shoulder exercises is not known definitively. Rehab first makes the most sense in the chronic tears, and then—if the shoulder remains painful—go for the repair.  

Older cuff tears may or may not be repairable depending on the health of the scarred tissue and the degree of arthritis in the joint. Even when repaired, some fail to heal. But, for some unknown reason, those attempted-but-failed repairs still provide pain relief and improved function. 

5) Ankle Ligament Tears. Most heal well without surgery and with excellent results if a brace and a physical therapy program are started early. Some go on to chronic ankle instability, with giving way and multiple ankle sprains. Those chronic tears can often be repaired with a simple reefing procedure of the ligament back to the bone. This repair, called a modified Brostrom, rarely fails. Since there is no downside to trying rehab first, this decision is “no incision.” 

The Bottom Line: Incise and repair orthopaedic tissues if more damage is going to be done by not repairing them early. If the downside to waiting and trying other strategies is low, the “no incision” decision looks pretty good.

Posted by Kevin R. Stone, M.D on July 22nd, 2017
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