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Minimallyinvasive Treatmentsofacuteachilles Tendonruptures: Milap S. Patel,, Anish R. Kadakia

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Minimallyinvasive Treatmentsofacuteachilles Tendonruptures: Milap S. Patel,, Anish R. Kadakia

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M inima lly I n vas i ve

Tre a t m e n t s o f A c u t e A c h i l l e s
Ten d o n R u p t u re s
a b,
Milap S. Patel, DO , Anish R. Kadakia, MD *

KEYWORDS
Achilles rupture Achilles repair Minimally invasive Achilles repair
Percutaneous Achilles repair

KEY POINTS
Achilles tendon rupture is a common injury to the lower extremity that requires appropriate
treatment to minimize functional deficit.
Current available treatments of Achilles tendon ruptures include nonoperative, open sur-
gical repair, percutaneous repair, and minimally invasive repair.
Open surgical repair obtains favorable functional outcomes with a significant potential for
deep soft tissue complications, calling into question the value of open repair.
Percutaneous repair is an alternative option with comparable functional results and min-
imal soft tissue complications; however, the risk of sural nerve injury is a known
complication.
Minimally invasive Achilles repair offers optimal results with superior functional outcomes
with minimal soft tissue complications and sural nerve injury.

INTRODUCTION

Should minimally invasive Achilles tendon repair be the new standard of treatment of
acute Achilles tendon ruptures?
Incidence of Achilles tendon rupture is highest in men between 30 years and
39 years of age.1,2 This incidence has been steadily increasing due to patients living
an increasingly active lifestyle.2–7 The Achilles tendon is one of the strongest tendons
in the body, yet it is most commonly affected by spontaneous ruptures. Ruptures
occur primarily in patients who participate in activities involving explosive acceleration
and maximal effort. Untreated Achilles tendon ruptures hinder an active lifestyle and

a
Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 259
East Erie, 13th Floor, Chicago, IL 60611, USA; b Department of Orthopaedic Surgery, North-
western Memorial Hospital, Northwestern University Feinberg School of Medicine, 259 East
Erie, 13th Floor, Chicago, IL 60611, USA
* Corresponding author.
E-mail address: kadak259@[Link]

Foot Ankle Clin N Am 24 (2019) 399–424

[Link] [Link]
1083-7515/19/ª 2019 Elsevier Inc. All rights reserved.

Descargado para Anonymous User (n/a) en Italian Hospital of Buenos Aires de [Link] por Elsevier en mayo 14, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
400 Patel & Kadakia

additionally have a detrimental effect on activities of daily living. Increased functional

length of the tendon in untreated patients results in significant weakness and altered
gait and is the underlying reason why operative fixation is considered for this
pathology.
Optimal treatment options for acute Achilles ruptures have been debated in the or-
thopedic literature for decades. In the past, the debate was concentrated on whether
conservative treatment was a superior option to open surgical management.
Currently, as technology and techniques have advanced, the debate has evolved to
include minimally invasive options that offer a similar advantage of tendon apposition
with limited surgical risk.
Modern treatment options for an acute Achilles tendon rupture include conservative
care (functional rehabilitation) and open, percutaneous, and minimally invasive or
limited open Achilles repair for acute midsubstance Achilles tendon ruptures. The
optimal treatment continues to be highly debated even though there have been rapid
advances in understanding of Achilles tendon injuries, surgical strategies, and surgical
techniques. Each option plays an important role in a carefully selected patient popu-
lation while providing unique risks and benefits. Current literature grazes over these
unique characteristics and seems to demonstrate many similar outcomes with small
differences. These small differences are important to understand and need to be scru-
tinized in great detail in order to provide patients with optimal care. The goal of treat-
ment is to return patients to full activity and try to achieve preinjury strength by
restoring physiologic tendon length and tension while subjecting patients to the fewest
complications.
Individual patients have different functional needs of their lower extremity depend-
ing on age, occupation, and/or activity level. Choice of treatment regimen ultimately is
up to the patient; the job of surgeons is to educate patients with current evidence-
based results. Outcomes also differ depending on patient compliance with treatment
regimen. The debate is not as simplistic as whether surgery or conservative treatment
is the best for an Achilles rupture; the real question is which treatment is best for a pa-
tient’s physiology and athletic demands.

ANATOMIC IMPLICATIONS

Because percutaneous and minimally invasive repair techniques are becoming more
prevalent, it is important to understand several important and relevant anatomic impli-
cations. With a thorough understanding of the anatomy, the safety of a minimally inva-
sive approach can be maximized.
The sural nerve has a variable course in the lower extremity, making it difficult to uti-
lize anatomic landmarks to trace out the nerve. Webb and colleagues8 performed
dissection of sural nerve in 30 cadavers. Proximally, the sural nerve crossed over to
the lateral border of the Achilles tendon at an average of 9.8 cm proximal to the Achil-
les insertion. At the Achilles insertion at the calcaneus, the sural nerve is 1.88 cm ante-
rior and lateral. Its pathway is crucial to understand because the sural nerve invariably
is in close proximity to the repair site on the lateral border of the Achilles tendon. The
sural nerve is located between fascia cruris and paratenon9,10; therefore, any repair
techniques that utilize sutures outside of the paratenon theoretically are at risk of
incarcerating sural nerve.
The Achilles tendon derives its vascular supply from posterior tibial artery and the
peroneal artery. The posterior tibial artery vascularizes the proximal and distal aspects
of the tendon and the peroneal artery vascularizes the central aspect of the tendon.11
The midsection of the tendon, approximately 4 cm to 7 cm from insertion, is

considered a hypovascular area with the poorest blood supply and has the highest
propensity to rupture.11
The skin over the Achilles tendon has a fragile vascular supply, which has resulted in
known complications, such as delayed wound healing and infection. Yepes and col-
leagues12 performed a digital vascular mapping of skin and subcutaneous tissue
over the Achilles tendon with arteriography to provide vascular safe zones for skin inci-
sion. A pattern of vascularity was noted in 10 fresh human cadaver legs over poster-
omedial, posterolateral, and posterior skin borders of tendon. More consistently, the
greatest amount of vascularization was noted between the axis of the medial malleo-
lus and the medial border of Achilles tendon. Additionally, the least vascularization of
skin and subcutaneous tissue was directly posterior. This vascular anatomy may
contribute to the wound complication risk in extensile open approaches.
Ankle position in a splint/cast after repair also can play an important role in providing
oxygenation to the skin over surgical repair site. Poynton and O’Rourke13 determined
skin perfusion by measuring transcutaneous skin oxygen pressure over the Achilles
tendon. It was determined that skin perfusion is maximal at 20 of ankle plantar flexion
and perfusion diminished by 49% at 40 of plantar flexion. Casting the ankle in 20 of
plantar flexion maximizes wound healing potential while taking tension off the repair
site. The authors have taken this concept to all posterior incisions, given the universal
nature of improving blood flow to the skin after surgery.
The Achilles tendon is unique in that it does not have a true synovial sheath but
rather a highly vascular paratenon. Paratenon serves several essential functions,
including providing a passageway for vascular supply in addition to allow for smooth
tendon gliding. Carr and Norris14 investigated vascularity of Achilles tendons in 16
fresh cadavers by injecting barium sulfate and India ink. They were able to demon-
strate numerous vessels evenly distributed throughout the length of paratenon even
over the watershed area of the tendon. During repair, it is imperative to minimize viola-
tion to paratenon and preserve its integrity to limit vascular insult to tendon as well as
prevent formation of future adhesion. The importance of paratenon repair has been
emphasized in recent literature as well.15
Carr and Norris14 also demonstrated several other vessels that ran into the mesote-
non toward the anterior aspect of the tendon providing additional blood supply. There-
fore, it is crucial to minimize any dissection at the anterior aspect of the tendon during
attempts at mobilizing a scarred down tendon. Although repair of the paratenon is
important, avoiding injury to the tendon via a minimally invasive approach is superior.

RATIONALE FOR NONSURGICAL MANAGEMENT

Proponents of nonsurgical management have always cited surgical complications as

the main disadvantage for surgical management.
Nonsurgical management options include cast immobilization or early functional
rehabilitation with functional bracing. Historically, cast immobilization has been the
preferred method of nonsurgical management. This consisted of immobilization in a
non–weight-bearing cast for 4 weeks followed by weight-bearing cast for another
4 weeks with restoration of ankle motion for a total of approximately 8 weeks in
cast immobilization.16–20 Several disadvantages with this management included sig-
nificant muscle atrophy, ankle stiffness, and loss of coordination and proprioception.
As more evidence-based data are presented, cast immobilization no longer is
justified and nonsurgical management has evolved toward use of early functional
rehabilitation with functional bracing. The term, functional rehabilitation, implies
early range of motion, protected weight bearing, or a combination of both.

Nilsson-Helander and colleagues21 performed a randomized controlled study, which

indicated that early functional rehabilitation is beneficial regardless of nonsurgical or
surgical management. Additionally, they were not able to demonstrate any statisti-
cally significant difference between the 2 groups. Willits and colleagues22 also per-
formed a randomized controlled study demonstrating support for nonsurgical
treatment with accelerated functional rehabilitation compared with surgical treat-
ment. Soroceanu and colleagues23 performed a meta-analysis of randomized trials
that demonstrated nonsurgical treatment with early functional rehabilitation resulted
in similar functional outcomes as surgical treatment. Twaddle and Poon24 and
Olsson and colleagues25 presented similar outcomes in their randomized study.
Wallace and colleagues26 achieved 2.8% rerupture rate with early functional rehabil-
itation in nonsurgically treated patients. Surgical complications can be avoided with
nonsurgical management with comparable outcomes, according to the previously
discussed studies.
Furthermore, functional rehabilitation has the added benefit of improved strength
characteristics of healed tendon,27–34 greater patient satisfaction,35–39 and improved
cartilage nutrition to hindfoot joints with preservation of range of motion.40 These
studies have convinced some surgeons to modify their practice into treating ruptures
predominantly nonsurgically.3,41
Failure of nonsurgical management is due primarily to improper apposition of
tendon stumps. Normal tendon healing response takes place regardless of tendon
stump proximity. With elongated Achilles tendon, end-range plantar flexion power is
decreased significantly through gastrocnemius-soleus complex.42 The musculotendi-
nous junction is relatively lengthened and cannot shorten effectively to generate
normal plantar flexion power. Weakness with toe-off and fatigue is a common
complaint in these patients.
Surgical management relies on complete apposition of tendon stumps to restore
tendon length and tension. Effective nonsurgical management relies on similar princi-
pals, which is why there are several objective measurements that ensure successful
outcome. These measurements utilize magnetic resonance imaging or dynamic ultra-
sound during initial evaluation. Nonsurgical management is effective if there is less
than 5 mm of gap with maximum plantar flexion, less than 10 mm of gap with foot
in neutral position, or with greater than 75% tendon apposition with foot in 20 of
plantar flexion.43,44
Ideal timing for initiation of successful nonsurgical treatment also has been
questioned.
Delayed presentation may hinder appropriate apposition of tendon stumps by a
well-organized hematoma. Young and colleagues45 were able to obtain rerupture
rates as low as 3% to 5% with casting by excluding patients from nonsurgical man-
agement who presented after 72 hours. Another study46 reported ideal timing for
nonsurgical management initiation to be less than 48 hours with inferior outcome
with plantar flexion strength after 1 week. The investigators did not comment on ideal
treatment between 3 days and to days from injury. Wallace and colleagues26 re-
ported clinically insignificant rerupture rate with nonsurgical management even
with delayed presentation at 2 weeks. Additionally, delayed presentation may lead
to more retraction of the tendon ends with interposed hematoma and predispose
to rerupture.
Ideal candidates for nonsurgical management include patients with significant med-
ical comorbidities that preclude anesthesia or those who cannot tolerate appropriate
positioning required for surgical repair. Patients who have sedentary lifestyle with low-
functional demand also may benefit from nonsurgical management.

RATIONALE FOR SURGICAL MANAGEMENT WITH MINIMALLY INVASIVE

TECHNIQUE

Historically, nonsurgical management have had significantly higher rerupture rates

compared with surgical management; however, surgical management is associated
with inherent risks to any surgery as well as increased risk of wound-related compli-
cations.16,20,47–53 Outcomes, in regard to rerupture rates, are not as well defined
with integration of functional rehabilitation.21–26 Even with advent of functional rehabil-
itation, there are numerous benefits to surgical management that need to be dis-
cussed further.
Willits and colleagues22 randomized 144 patients to either nonsurgical or open sur-
gical repair along with accelerated functional rehabilitation; 72 patients were random-
ized to nonsurgical treatment group and the other 72 to surgical treatment group.
Rerupture occurred in 2 of the surgical treatment group and in 3 of the nonsurgical
treatment group. There were 4 superficial infections, 1 deep infection, 2 wound com-
plications, 1 skin puckering, and 1 with hypertrophic scar in the surgical group. None
of these complications was found in the nonsurgical treatment group. Deep venous
thrombosis (DVT) was present in 1 in surgical and nonsurgical group whereas pulmo-
nary embolism was present in 1 surgical group. Overall, the surgical group had a total
of 13 complications compared with 6 in the nonsurgical group. A majority of surgical
complications were soft tissue related. Overall, this study demonstrated clinically
similar outcomes between 2 managements. At 1-year and 2-year velocity testing,
the surgical group demonstrated higher plantar flexion strength ratio at 240 /s
compared with the nonsurgical group. The difference was small but statistically
significant. Although clinical relevance of this increase in plantar flexion strength
may be unclear, it can provide increased power to an athlete. Cetti and colleagues16
demonstrated a higher rate of resuming sports activities after surgical repair.
Soroceanu and colleagues23 recently performed a meta-analysis of randomized tri-
als comparing surgical to nonsurgical management demonstrating similar rerupture
rates between managements if functional rehabilitation is used. Surgical management
did have lower rerupture rate, however, if functional rehabilitation was not used in
nonsurgical patients. Additionally, surgical patients returned to work 19.16 days
sooner. Earlier return to work with less sick leave absences in surgical compared
with nonsurgical patients is a clear benefit in returning patients to routine daily function
and has been demonstrated by multiple studies.16,18,20,39,54
Olsson and colleagues25 performed a randomized controlled study involving 100
patients randomized to nonsurgical management and surgical management with
open repair followed by an accelerated rehabilitation protocol. No significant differ-
ence between groups in terms of symptoms, physical activity level, or quality of life
was observed. The surgical group had 0 reruptures compared with the nonsurgical
group, with 5; however, this difference was not statistically significant. There were 6
superficial infections in the surgical group all managed with antibiotics without any
long-term deficit. In functional testing, the surgical group demonstrated a trend toward
superior results; however, significantly superior results in drop countermovement
jump and hopping were noted.
Nilsson-Helander and colleagues21 performed a randomized controlled trial with 49
patients in surgical group and 48 in nonsurgical group. Open surgical repair was used
followed by accelerated functional rehabilitation. There were 6 (12%) reruptures in
nonsurgical group, as opposed to 2 (4%) in surgical group. This was not statistically
significant; however, this may be a function of the relatively small number of patients.
The surgical group achieved greater improvement in muscle function test in heel-rise

work, heel-rise height, concentric power, and hopping tests at the 6-month evaluation
than did the nonsurgical group. There were no differences, however, between groups
at the 12-month evaluation, except on the heel-rise work test in which the surgical
group performed significantly better than the nonsurgical group. It is possible that sur-
gically managed patients were more confident in their surgical repair and were more
aggressive during rehabilitation, resulting in faster improvement in function.
Existing randomized controlled trials comparing surgical and nonsurgical man-
agement may not be adequately powered to detect differences in function and
overall outcomes. After reviewing the literature and analyzing small important differ-
ences, however, surgical management clearly demonstrates increased plantar
flexion strength,22 higher rate of resuming sporting activities,16 earlier return to
work,16,18,20,23,39,54 superior functional outcome especially in drop countermove-
ment jump and hopping,25 and faster rehabilitation.21 Although a majority of these
studies do not demonstrate statistically significant difference in rerupture rates, all
studies have less number of reruptures in surgical groups compared with nonsur-
gical groups, and this may be clinically relevant to some surgeons.
A major advantage of surgical management is the ability to approximate the
ruptured tendon stumps to re-establish tendon length. With restoration of tendon
length, gastrocnemius–soleus–Achilles tendon complex tension and muscle integrity
are restored, resulting in improved functional outcome. Surgical management gener-
ally is divided into open, percutaneous, and minimally invasive or limited open repair.
Potential complications include superficial and/or deep infection, delayed wound
healing, wound necrosis, adhesion formation, sural nerve injury, rerupture, and DVT.
Injury to the sural nerve results in symptoms that can range from simple annoyance
to severe pain, resulting in significant debilitation by making routine tasks, such as
dressing, finding comfortable shoes, and foot/ankle position, difficult. If a painful neu-
roma does not respond to conservative management, including medication, desensi-
tization therapy, or nerve blocks, proximal sural nerve excision and burial are
recommended. Open repair is associated with as high as 6% sural nerve injury51;
meanwhile, with percutaneous repair, it has been reported as high as 60%.55 Mini-
mally invasive techniques with a subparatenon placement of the suture, however,
have significantly lower rates of injury compared with both open and percutaneous,
as discussed later.
Delayed wound healing can be managed with wet to dry dressing or silver sulfadia-
zine cream. A larger wound dehiscence occasionally needs a negative-pressure
wound therapy to assist with wound closure. Persistently large soft tissue defect after
appropriate management warrants plastic surgery involvement for definitive wound
coverage.
Superficial wound infection is managed with oral antibiotics if evaluated early. Deep
infection is a major complication that has to be managed surgically. In some cases,
irrigation and débridement along with intravenous antibiotic are sufficient. In most
cases, all infected tissue and foreign material used for repair should be excised. If pri-
mary repair is compromised, revision should be performed after infection has been
eradicated at a delayed setting. Depending on quality of tendon at time of revision,
allograft, fascial augmentation, or flexor hallucis longus tendon transfer may be neces-
sary to augment the repair. Deep infection requiring reconstruction can provide
acceptable function; however, it carries morbidity to the patient and high cost to the
health care system and does not compare to a successful open repair with regard
to function.
Because open surgical repair is associated with high complication rates and poten-
tially devastating outcomes, percutaneous repair techniques were developed. This

technique indirectly approximates ruptured tendon stumps without exposure at the

rupture site, thereby sparing any violation to paratenon and surrounding soft tissue.
Ma and Griffith56 initially developed a method of percutaneously repairing Achilles
tendon ruptures to create a compromise between nonsurgical and surgical open
repair pitfalls. Repair was performed within 3 days of injury under local anesthesia
without tourniquet. This technique involves 3 small stab incisions through subcu-
taneous tissue on medial and lateral aspect of the Achilles tendon followed by pas-
sage of nonabsorbable suture through the tendon. The sutures were tied on the
medial aspect of the rupture site outside of the paratenon; 18 patients underwent
this repair and ankle power was restored to 89% of contralateral lower extremity
at 2 years. There were 2 minor complications reported. Both were related to symp-
tomatic suture knot, which resolved after excision of these suture knots. Complica-
tions, including superficial and/or deep infection, wound necrosis, and sural nerve
injury, were not reported. This was not a randomized study, but it was able to effec-
tively restore tendon function without a formal open approach while avoiding asso-
ciated complications.
Hockenbury and Johns55 performed an in vitro study comparing 5 specimens
repaired with percutaneous repair using the Ma and Griffith technique and 5 speci-
mens repaired with an open technique in fresh-frozen below-the-knee specimens.
Postrepair dissection demonstrated 3 of 5 cadaver specimens having sural nerve
entrapment in percutaneous group.
Other percutaneous techniques57,58 have surfaced in literature since the introduc-
tion of the Ma and Griffith technique but are not popularized due to associated com-
plications. Delponte and colleagues58 developed a modified percutaneous technique
by using 2 harpoon-like devices, called Tenolig, FH Orthopedics (Chicago, IL), which
are preloaded with sutures, to be inserted approximately 6 cm proximal to rupture site
and exit 4 cm to 5 cm distal to the rupture site. The sutures have a metallic barblike
structure that adheres to the proximal tendon stump and pulls the tendon distally
when the sutures are pulled. When appropriate tension is obtained, the sutures are
locked to a metallic disc by a crimper that sits superficial to skin for 6 weeks at exit
site. This technique had promising results initially; however, Maes and colleagues59
demonstrated unusually high complication rates in 124 cases, including unbending
of harpoon in 5 cases, wire rupture in 1 case, skin necrosis at entrance wound in 10
cases, tendon rerupture in 12 cases, and sural nerve injury in 8 cases.
There is not abundant literature that compares outcomes between nonoperative
and percutaneous repair. Rowley and Scotland60 compared outcomes in 14 patients
who underwent immobilization in equinus position casting and 10 patients who under-
went percutaneous repair. No complications were noted in equinus casted patients.
One of 10 patients who underwent percutaneous repair suffered from sural nerve
entrapment. Patients who were managed with percutaneous repair were more likely
to regain nearly normal plantar flexion strength and returned to activity sooner than
the group managed with equinus casting. This study does demonstrate percutaneous
repair group did functionally better against immobilization group; however, acceler-
ated functional rehabilitation has showed to be a superior nonsurgical management
and should ideally be compared to this. There are several studies that compare out-
comes of conventional open repair techniques with that of percutaneous.
Haji and colleagues61 conducted a retrospective analysis comparing 70 open Achil-
les repairs to 38 modified Ma and Griffith percutaneous repairs. Subjective analysis of
functional outcomes demonstrated higher percentage of patients with normal range of
motion and higher plantar flexion power in the percutaneously repaired group. There
were 4 (5.7%) ruptures in open repair compared with 1 (2.6%) in percutaneous.

Increased deep infections were noted in open repair at 4 (5.7%) compared with 0 (0%)
in percutaneous. Decreased sural nerve injury were noted in open repair at 1 (1.4%)
compared with 4 (10.5%) in percutaneous. The sural nerve lesions in percutaneous re-
pairs were transient in nature and resolved during the follow-up period.
Recently, Rozis and colleagues62 performed a prospective study with 82 patients
who were randomized into open repair group or percutaneous repair group using
the Ma and Griffith technique. The open repair group had 3 (7%) infections whereas
percutaneous repair had 0 (0%). There were 2 patients with superficial infection, which
were eradicated with oral antibiotics, and 1 patient developed skin necrosis, which
necessitated plastic surgery coverage with rotational skin flap. The percutaneous
repair group had 3 (7.3%) patients with sural nerve injury and 0 (0%) in open repair
group. There were no reruptures in either group.
Compared with open repair, percutaneous techniques did bring the wound-
related complication to a negligible amount; however, they do increase iatrogenic
injury to the sural nerve. Incidence of sural nerve injury rates after percutaneous
repair vary according to literature. Ma and Griffith56 reported 0 cases of iatrogenic
sural nerve injury. Meanwhile, Klein and colleagues63 used the Ma and Griffith tech-
nique in 38 patients and reported 5 (13%) sural nerve entrapment as well as 3 (7.8%)
reruptures. Other investigators have noted sural nerve injury rate as low as 7.3%62
and as high as 60%.55 Majewski and colleagues64 published a retrospective case-
control study demonstrating how to avoid sural nerve injury during percutaneous
repair. A total of 84 patients were retrospectively analyzed at 2 different hospitals
undergoing the same percutaneous repair technique, except that the sural nerve
was exposed in 1 hospital and sural nerve was not exposed in the other. The overall
incidence of sural nerve injury was 18% in the nonexposed group and 0% in the
exposed group. Percutaneous repair strength was called into question by Hocken-
bury and Johns55 who performed an in vitro biomechanical testing in 5 cadavers af-
ter repair demonstrated that tendons that underwent open repair were able to resist
almost twice the amount of ankle dorsiflexion (27.6 ) before appearance of a 10-mm
gap compared with percutaneous repair (14.4 ). These results are not clinically rele-
vant because during the early postoperative period, accelerated rehabilitation does
not allow for forced dorsiflexion. Cretnik and colleagues65 performed a biomechan-
ical testing on 36 cadavers demonstrating the modified Ma and Griffith technique
having greater tensile strength and gapping resistance compared with the standard
Ma and Griffith technique. This does not compare directly open to percutaneous
repair strength, but it does demonstrate the modified techniques to have greater
mechanical strength immediately after surgery. More recently, Goren and col-
leagues66 compared 10 patients with the Ma and Griffith percutaneous repair to
10 patients with open repair. Dynamometer strength evaluation revealed 16% loss
of strength in percutaneous group and 18.2% in open group compared with the
contralateral side. Even if the rate of sural nerve injury can be minimized by exposing
sural nerve and comparable repair strength can be obtained by integrating a
different technique, another major drawback of percutaneous technique is its
inability to visualize direct apposition of ruptured stumps, which can potentially
result in malalignment of tendon stumps.
Both open and percutaneous repair techniques provide similar functional outcome.
The major difference lies in that open repair is much more destructive to soft tissue
that may account for the significant thickening associated with the repair and the
deep wound complication rate. Percutaneous techniques provide soft tissue friendly
repair, but it has its own unique complications with sural nerve injury and inability to
visualize tendon apposition. Minimally invasive repair techniques take the benefit of

both the open and percutaneous techniques while minimizing their associated
complications.
Amlang and colleagues57 developed a technique where a Dresden instrument was
inserted 2 cm to 3 cm proximal to rupture site through a small incision. The instrument
was advanced distal to rupture site between fascia cruris and paratenon. Sutures were
inserted percutaneously through this instrument and pulled out through proximal inci-
sion. After appropriate tension was obtained, the sutures were tied in the proximal
portion of the rupture. The investigators claimed 2 of 62 cases having reruptures
and 0 cases of sural nerve injury with 62% with very good outcomes. Keller and col-
leagues67 also demonstrated favorable outcomes with 100 percutaneous repairs with
Dresden technique. This technique has garnered a significant following in Europe and
South America.
Kakiuchi68 took advantage of best aspects from open and percutaneous repair
techniques and applied them to a newer technique, where looped Kirschner wires
were inserted deep to paratenon from the tendon rupture site using a limited open inci-
sion. This allowed sutures to be placed deep to paratenon and retrieved from the
ruptured site. With this technique, there was decreased chance of injury to the sural
nerve and direct visualization of end-to-end tendon apposition at repair site. With
increased functional outcomes69 along with minimal wound and sural nerve complica-
tion rates compared with open and percutaneous repair, this technique laid the foun-
dation for current minimally invasive repair techniques.
Assal and colleagues70 developed the Achillon (Integra LifeSciences, Plainsboro,
New Jersey) device based on Kakiuchi’s technique. This device is a guiding instru-
ment with inner and outer corresponding arms. This instrument is inserted deep to
paratenon around the Achilles tendon from the rupture site using a 2-cm longitudinal
incision. When the instrument is around proximal ruptured stump, 3 sutures are
passed and instrument is removed, leaving 6 suture strands exiting from the incision.
The same is done for distal tendon stump using same incision. After appropriate ten-
sion is achieved, the sutures are tied to each other in a proximal to distal fashion
creating 3 box suture configurations. In 82 patients, there were 0 cases of wound com-
plications, 0 cases of infection, 0 sural nerve disturbances, and 3 reruptures. Two pa-
tients were noncompliant with postoperative protocol and a third patient fell at
12 weeks. Mean AOFAS score at 26-month follow-up was 96 points and all patients
returned to previous work/sporting activities. There was no significant difference in
the mean number of single-limb hops and plantar flexion strength between injured
and uninjured sides.
Calder and Saxby71 published outcome in 46 repairs with Achillon. There was 1 su-
perficial wound infection, which subsided after oral antibiotics; 2 cases of temporary
sural nerve paresthesias, which resolved spontaneously at 3 months; and 0 reruptures.
An average American Orthopaedic Foot & Ankle Society score of 98.4 was obtained
and all patients returned to previous levels of sporting activities by 6 months. They
suggested Achilles repair allowed active mobilization and earlier return to sporting
activities.
Several studies were published comparing outcomes between Achillon and open
repairs.72–76 Atkas and Kocaoglu72 prospectively analyzed outcomes in 40 patients.
There was no significant difference in AOFAS score at 22.4-month follow-up. Local
tenderness, skin adhesions, and scar and tendon thickness were better in the Achil-
lon group. In the Achillon group, there was 0 reruptures, 0 sural nerve injuries, 0 su-
perficial or deep infections, and 0 adhesions. Bhattacharyya and Gerber74
prospectively compared 59 patients and showed decreased operating time, less
bed usage, less consumption of postoperative analgesics, fewer associated indirect

costs to the health care provider, and no postoperative morbidity. In the Achillon
group, there were 0 reruptures, 0 sural nerve injuries, 0 superficial or deep infec-
tions, and 0 adhesions. Kolodziej and colleagues75 randomized 47 patients and
were able to demonstrate 0 reruptures, 0 sural nerve injuries, 0 deep infections, 1
superficial infection, and 0 adhesions. Valencia and Alcalá76 demonstrated 0 rerup-
tures, 0 sural nerve injuries, 0 superficial or deep infections, and 1 adhesion in the
Achillon group. More recently, a meta-analysis by Alcelik and colleagues73 demon-
strated similar outcomes.
To assess strength, Ismail and colleagues77 compared pull-out strength of Achillon
and Kessler repairs in ovine (sheep) tendons. Mean load to failure with 3-strand Achil-
lon repair was 153 N 60 N and in Kessler repair was 123 N 24 N. This demon-
strates that the Achillon system is capable of producing a biomechanically sound
repair. Huffard and colleagues78 demonstrated similar results in 10 cadavers when
compared Krackow suture configuration to Achillon. Mean load to failure in Krackow
suture configuration was 276 N; meanwhile, it was 342 N in Achillon. Similar results
were demonstrated by Heitman and colleagues.79
Achillon was able to effectively provide benefits of percutaneous repair without the
complications of open repair, but there were some deficiencies. The jig is not very
stout and has a risk of missing needle passes through bending moment because it
was made out of polycarbonate. It is a single-use device that resulted in increased
cost to health care system. The jig is straight and nonanatomic by design. As a result
of the design, occasionally, it is difficult to pass around the torn tendon stump while
pulling counterpressure. All 3 sutures pass through the tendon in the same transverse
plane predisposing it to early failure through suture cut-out. Lastly, all sutures were
sliding suture and there was no option of locking suture construct. In 2010, a newer
instrumentation, called Percutaneous Achilles Repair System (PARS) (Arthrex, Naples,
Florida), was developed by making improvements on these shortcomings. The PARS
jig is metallic and nondisposable to save costs to health care. The metallic character-
istic makes it stout and less prone to bending during passage, decreasing the risk of
the needles missing the inner arms of the jig. Its design is more anatomic with anterior
contour, which easily glides around the tendon stumps while applying counterpres-
sure. Lastly, there is possibility of inserting up to 7 different sutures at once in multiple
planes with an option of making all sutures transverse or up to 2 locked suture
configurations.
To date, there has only been 1 study published comparing outcomes between
PARS to open repair. Hsu and colleagues80 retrospectively reviewed 101 PARS to
169 open repair patients. It demonstrated a greater number of patients returning
to baseline physical activities by 5 months in PARS (98%) compared with the
open group (82%). In the open group, there were 0 reruptures, 0 DVT, 5 cases
(3%) of sural neuritis, 7 cases (4%) of superficial wound dehiscence, 3 cases
(2%) of superficial infection, and 3 reoperations (2%) for deep infection. In the
PARS group, there were 0 reruptures, 0 cases of sural neuritis, 0 cases of DVT, 3
cases (3%) of superficial wound dehiscence, and 2 operations (2%) for superficial
foreign-body reaction to FiberWire, Arthrex (Naples, FL) without concurrent infec-
tion. Overall, the complication rates in the open group were 10.6% (18 cases) and
5.0% (5 cases) in PARS group.
Several biomechanical tests have been published demonstrating superior construct
strength of PARS. Demetracopoulos and colleagues81 compared strength of mini-
mally invasive repair using nonlocking sutures (Achillon) to a combination of locking
and nonlocking sutures (PARS) in 31 cadavers. It was clearly demonstrated that
locking suture construct was able to without more cyclical loading prior to detection

of 2-mm and 9.5-mm tendon gaps as well as withstanding significantly greater load to
failure compared with a nonlocking suture construct (299.6 N vs 385 N). Recently,
Dekker and colleagues82 biomechanically compared Krackow suture construct to
limited open repair using PARS in 18 cadavers. Average load to failure was 353.6 N
in the open group compared with 313.3 N in the PARS group, which was not statisti-
cally significant. Mean initial linear clinical findings since testing is done representing
the immediate intraoperative repair; meanwhile, it is a known that early motion along
with progressive loading increased tendon strength.
Another advantage of minimally invasive repair is cosmesis. Although this may not
directly improve functional outcome, patient satisfaction is increased if similar out-
comes are provided with smaller incision. Del Buono and colleagues83 performed a
systematic review of 12 studies comparing open and minimally invasive repairs in
781 patients. They reported 3.4-cm average length of incision for the minimally inva-
sive group compared with 12 cm for the open repair group (Fig. 1).
Appropriate selection and meticulous surgical techniques maximize functional
outcomes while minimizing complications. Repair is advocated in all active patients
if optimum performance is desired. It should be used in athletes and in patients who
have high activity level. Nonsurgical management is reserved for older (over 60),
sedentary, or debilitated patients. Minimally invasive surgery provides benefits of
functional outcome that is obtained with open surgical approach without the soft tis-
sue complications. With advances in surgical instrumentations and techniques,
minimally invasive Achilles tendon repair has provided sufficient data to justify its
use for repairs. Minimally invasive repair has definitively demonstrated superior
overall outcomes with decreased surgical complications compared with open repair.
Because there is no agreed-on treatment regimen, the choice of treatment is based
largely on preference of surgeon and the patient; however, the authors believe,
based on their experience and the evidence provided by the literature, that minimally
invasive repair techniques should be the new gold standard treatment of acute mid-
substance Achilles tendon ruptures. Regardless of surgical technique that is chosen,
a functional rehabilitation protocol is advocated to maximize the functional outcome
(Table 1).

Fig. 1. A 3-month postoperative photograph after PARS repair of an acute Achilles tendon
rupture (A - at neutral, B - plantarflexion). Note the minimal thickening and the ability to
perform a double limb heel rise with minimal calf atrophy seen.

Table 1
Postoperative functional rehabilitation protocol

Week 0–2 Non–weight-bearing splint in place

Week 2 Postoperative splint is removed and removable boot is applied with heel lifts
to maintain 20 plantar flexion.
Weight bearing is initiated and progressed as tolerated
Soft tissue/scar mobilization
ROM exercise: plantar flexion/dorsiflexion from 20 to full plantar flexion, 2
sets of 20 repetitions; circumduction (both directions), 2 sets of 10
repetitions
Strengthening exercise: isometric inversion/eversion, 2 sets of 10 repetitions
with ankle at 20 of plantar flexion; toe curls with towel and weight;
hamstring curls in prone with boot on for resistance, 2 sets of 10 repetitions
Cryotherapy
Week 3 Progress weight bearing to full weight as tolerated in boot with 2 heel lifts.
Soft tissue/scar mobilization
Begin stationary bike in boot with low resistance.
Aqua therapy may begin without any weight bearing by using a flotation
device. ROM, walking, or running in the water is done to preserve fitness
level. Aqua therapy is not necessary but, if available, may be used.
ROM exercise: continue as before; may progress to gentle stretch to neutral
ankle position with use of strap or towel
Strengthening: isometric inversion/eversion, dorsiflexion/plantar flexion 2
sets of 10 repetitions to progress to 2 sets of 20 repetitions over the course of
week 3; begin light band–resisted inversion, eversion, dorsiflexion, and
plantar flexion, 2 sets of 10 repetitions. Prone knee flexion, 2 sets of 20
repetitions
Cryotherapy
Weeks 4–6 Weight bearing to full in boot brace with heel lift
Take 1 lift out at week 5.
Take the other lift out at week 6; therefore, at 6 weeks should be in the boot
with no lifts.
Gentle cross-fiber massage to Achilles tendon
Ultrasound, phonophoresis, electrical stimulation used to decrease
inflammation and scar formation.
Stationary bike up to 20 minutes, with minimal resistance and aqua therapy
as outlined in week 3
Gentle stretching of Achilles tendon with towel or in standing (if limited
to less than neutral position only). Stretch with knee extended and flexed
to 40 .
Strengthening: isometric exercise as on week 3; increase resistive band
exercise for plantar flexion, dorsiflexion, inversion, and eversion; 3 sets of 20
repetitions.
Hamstring curls to facilitate gastrocnemius muscle without flexing the
ankle. May be done in prone or standing with light resistance; 3 sets of 20
repetitions
Weeks 6–7 Patient progresses from boot to shoe with heel lift.
Stationary bike without boot and with progressive resistance
Gentle stretching exercise to neutral ankle position
BTE passive ROM, isometric, and isotonic exercise
Weight shifting and unilateral balance exercise seated on therapeutic ball
Closed chain, partial weight-bearing strengthening of plantar flexors
(neutral through full plantar flexion)
Seated heel raises
Total gym heel raises (low angle)

(continued on next page)

Table 1
(continued )
Hamstring curls with light resistance
Open chain strengthening of foot and ankle musculature band (light to
medium resistance)
Gait training with concentration on weight shifting heel to toe over
involved foot and side to side weight shifting
Begin stair stepper with involved limb only.
Aqua therapy (especially good for obese patients to initiate weight bearing
activity and athletes to maintain conditioning): walking in water (waist
deep or greater), standing heel raises (water at least waist deep or greater),
flutter kick with kick board (with or without fins as tolerated), conditioning
exercise
Soft tissue mobilization
Modalities to control edema and pain
Weeks 8–9 Patient is wearing shoe full time with heel lift
Stationary bike—increased resistance and time
Gentle stretching up to neutral ankle dorsiflexion if needed
Gait training—step over progressively higher steps as able
BTE isotonic and isometric exercise for plantar flexion strengthening
(eccentric bias)
Band-resisted inversion and eversion in seated position with foot flat on the
floor and band around ankle
Band-resisted dorsiflexion (open chain)
Total gym with increased angle for heel raises and short arc squats. Begin
unilateral eccentric plantar flexion exercise.
Short arc squats in standing
Hamstring curls (progressive resisted exercise)
Progress to standing heel raises using uninvolved LE to assist involved LE
Progress to standing balance exercise in tandem and then single-leg support
Aqua therapy (obese patients may progress more slowly and refine
ambulation quality in pool): walking in water, standing heel raises (water at
least waist deep), flutter kick with kick board (with or without fins),
plyometrics, conditioning exercise
Weeks 10–12 Patient wearing shoe without lift
Stationary bike (warm up and/or aerobic conditioning)
Gentle stretching in standing past neutral
BTE strengthening
Standing balance exercise with/without eyes closed
Perturbation
BOSU ball
Airex pad
Band resist
Ball toss
Squats with moderated resistance (limit ankle dorsiflexion)
Hamstring curls with resistance
Standing heel raises (2 feet with progression to single limb for eccentric
strengthening, then eccentric/concentric strengthening as able)
Total gym single-heel raise
Resisted walking: free motion machine, pulleys, bands
Elliptical trainer
Aqua therapy (for obese patients to progress walking tolerance and
endurance, heel raises and aerobic conditioning; for athletes to progress
plyometrics and aerobic conditioning)

(continued on next page)

Table 1
(continued )
Weeks 12–14 Stationary bike (warm up and/or aerobic conditioning)
Gentle stretching
Balance exercise with perturbation in single limb support unless within
normal limits and equal bilaterally
Resisted bilateral heel rises with free motion, calf machine
Unilateral heel rises if able or eccentric unilateral heel rises
Elliptical trainer
Week 14 and If patient is able to perform a single leg heel rise 10 times and has low pain
beyond rating may progress to
Stair stepper
Plyometrics training (begin with 1 feet and progress to single-limb jumps)
Jogging—slow speed and limited distance, with progression as symptoms
permit

Abbreviations: LE, lower extremity; ROM, range of motion.

AUTHORS’ PREFERRED TECHNIQUES FOR MINIMALLY INVASIVE ACHILLES REPAIR

Percutaneous Achilles Repair System
Indications
Primary repair of Achilles tendon rupture occurring approximately 2 cm to 7 cm
proximal to calcaneal insertion
Acute Achilles tendon ruptures (<3 weeks) are ideal with this technique. Tears
that are older than 3 weeks are amenable with this technique as long as scar tis-
sue adhesions between tendon and paratenon are freed up and tendon is mobi-
lized adequately.

Contraindications
Insertional Achilles tendon ruptures are not amenable to be repaired with this tech-
nique and the use the Midsubstance SpeedBridge (Arthrex) technique is preferred.
Chronic Achilles tendon ruptures of greater than 6 weeks occasionally require
additional procedures to augment repair, which is routinely performed through
an open approach.

Equipment
PARS jig and PARS suture system

Patient positioning
General or regional anesthesia can be used, although regional is preferred when
feasible. The authors do not use a tourniquet; however, if desired, the tourniquet
should be placed on the thigh, not the calf, to avoid limiting the excursion of the
gastrocnemius-soleus complex.
This technique is performed with patient in prone position. The affected extremity
is at the edge of the table and propped up with blankets so it is sitting higher than
contralateral extremity. Passing of needles through the PARS jig is easier with
affected extremity positioned higher.

Surgical technique
A 2-cm longitudinal incision is made paramedially, beginning 1 cm proximal to
distal stump extending superiorly. This can be extended proximally or distally

as required. A transverse incision is another alternative; however, a Z-shaped

extension of incision is required if more visualization is needed proximally or
distally. Given the ability to plantar flex the foot that allows the distal stump to
be delivered into the wound, the incision is ideally based at the level of the prox-
imal stump (Fig. 2).
Skin hooks are used for retraction to minimize damage to skin with pickups. Par-
atenon is sharply incised followed by blunt dissection.
A finger or freer elevator is used for blunt dissection to free up any adhesions at
the proximal and distal stumps.
An Allis clamp is used to grasp proximal stump within the paratenon and pulled
longitudinally through the incision (Fig. 3). Occasionally, a second Allis clamp can
be used to grasp the tendon more proximally while pulling on the first Allis clamp
to grasp better quality tendon. If questioning whether the proximal stump is
grasped adequately, a hand can be placed over the calf while tugging on an Allis
clamp and the gastrocnemius-soleus complex should be palpated and distal
translation should be noted.
The PARS jig is now inserted into the proximal paratenon sheath with the inner
arms around the proximal stump. Once the arms are within the paratenon sheath,
the arms are opened up progressively and advanced proximally while keeping
counterpressure on the Allis clamp.
If the inner arms are correctly positioned next to the tendon, the outer aiming
arms should be positioned in the posterior one-fourth of the leg longitudinally

Fig. 2. Patient is placed prone with a 2-cm incision centered over the proximal stump. On
first utilizing this technique, a larger incision can be used; however, with repeated use,
the incision can be routinely made less than 2 cm.

Fig. 3. An Allis clamp is utilized to hold tension while the PARS jig is inserted (A - inferior
view, B - superior view).

when visualized from medially or laterally. Occasionally, the Achilles tendon

stump can be easily palpated sitting between the 2 inner arms.
While gently pulling on the Allis clamp and the jig in neutral position, a suture
passing needle is inserted through hole 1. This needle essentially locks the
tendon to the jig and is left in this position.
A bump made out of stacked towel can be placed under the ankle to make nee-
dle passes easier.
A second suture passing needle is passed through hole 2. Pass blue/white suture
through the eyelet and the needle is pulled out from hole 2 (Fig. 4).
Same suture passing needle is passed through hole 3. Pass looped end of green/
white suture through the eyelet and the needle is pulled out from hole 3.
Same suture passing needle is passed through hole 4. Pass nonlooped end
of green/white suture through the eyelet and the needle is pulled out from
hole 4.
Same suture passing needle is passed through hole 5. Pass black/white suture
through the eyelet and the needle is pulled out from hole 5.
If a second locked suture is desired, black/white suture from hole 5 can be used
in this manner by passing looped sutures through hole 6 and 7 in similar fashion
as hole 3 and 4.
A white suture is passed through eyelet of needle in hole 1 and needle is pulled
out (Fig. 5).
PARS jig is retracted out of the wound while closing the inner arms. This ensures
the sutures are through the tendon and within the paratenon sheath. Once the
sutures are out of the wound, carefully pull out sutures from the jig and organize
them in order they were inserted.
On each side, hold both green/white sutures in 1 hand and pass the blue suture
around the 2 green/white sutures twice and pass end of blue suture through the
loop.

Fig. 4. The first needle is left in place allowing the PARS jig to hold the position of the prox-
imal stump. The second suture is passed with ease, followed by the remaining 4 sutures in
sequential order.

Fig. 5. All 5 sutures have been passed and the lengths equalized and the jig is then removed
followed by locking of the central suture.

Pull the unlooped green/white suture on each side while the blue suture is still
through the loop. This pulls the blue suture to the contralateral side and create
a locking suture construct. Make sure not to dispose looped sutures because
these will be used for distal stump.
Pull on the blue sutures to remove any slack and minimize creep.
Pull on the white and black/white suture individually to ensure suture does not
pull through tendon. If either suture pulls out, the jig is reinserted and suture-
passing needle is passed with its designated suture.
The jig is re-inserted into the distal stump and the same order for suture passing
is conducted as detailed for the proximal stump.
Once all sutures are passed, there should be 3 sutures with excellent tension
proximally and distally on each side (Fig. 6).
The sutures are tied down with the foot held in plantar flexed position by an as-
sistant. The black/white sutures are tied on 1 side of the tendon initially. Because
this is a nonlocked suture, the knot on the tied side can be slid proximally or
distally by pulling on the free suture on contralateral side. The authors prefer to
pull on the free suture to pull knot on contralateral side proximally into the wound
so it is not prominent under the incision. The other side of black/white suture is
tied next (Fig. 7).
The blue locking sutures are tied on both sides.
The white suture is tied on 1 side followed by shuttling the knot more proximal
by pulling on contralateral free suture. The other side of white suture is tied
next.

Fig. 6. Appearance of the incision and the final 3 sutures (central one is locked) securing the
proximal stump.

Fig. 7. Visualization of tendon apposition during placement of the knots to complete the
repair. The ability to visualize the apposition of the tendon without requiring a large soft
tissue exposure is a key advantage of this technique compared with an open or percuta-
neous approach.

The repair is tested by restoration of Thompson test and with moderate dorsiflex-
ion pressure on the foot. If the repair fails with gentle pressure or there is no
plantar flexion with calf squeeze, the quality of the repair should be re-
evaluated and revised if needed.
Paratenon is approximated with 2-0 Vicryl suture.
Subcutaneous tissue is approximated with 3-0 Monocryl suture.
Skin is approximated with 3-0 nylon suture.

Midsubstance Speed Bridge Repair

Indications
Primary repair of Achilles tendon rupture occurring approximately 1 cm to 7 cm
proximal to calcaneal insertion.
Acute Achilles tendon ruptures (<3 weeks) are ideal with this technique. Tears
that are older than 3 weeks are amenable with this technique as long as scar tis-
sue adhesions between tendon and paratenon are freed up and tendon is mobi-
lized adequately.

Contraindications
Chronic Achilles tendon ruptures of greater than 6 weeks occasionally require
additional procedures to augment repair, which is routinely performed through
an open approach.

Equipment
PARS jig and PARS suture system
Achilles Midsubstance SpeedBridge system

Patient positioning
General or regional anesthesia can be used.
This technique is performed with patient in prone position. The affected extremity
is at the edge of the table and propped up with blankets so it is sitting higher than

contralateral extremity. Passing of needles through the PARS jig is easier with
affected extremity positioned higher.
The authors do not use a tourniquet, but a thigh tourniquet can be used per sur-
geon preference.

Surgical technique
A 3-cm longitudinal incision is made paramedially 1 cm proximal to distal stump.
This can be extended proximally or distally as required. A transverse incision is
another alternative; however, a Z-shaped extension of incision is required if
more visualization is needed proximally or distally.
The PARS technique is used in the proximal tendon stump, as described
previously.
A stab incision is made over the calcaneus on the medial and lateral aspect of the
Achilles insertion site.
A 3.4-mm drill bit is used to create anchor point at these stab incisions. Trajectory
of the drill should be distally and toward the midline. Bony debride in these an-
chor points is irrigated with fluid.
These holes are then tapped with 4.75-mm Bio-SwiveLock (Arthrex) anchors.
A Banana SutureLasso (Arthrex) tip is passed retrograde via these stab inci-
sions passing through medial and lateral aspect of the distal tendon stump
(Fig. 8).
The nitinol wire loop is advanced within the Banana SutureLasso to allow pas-
sage of proximal sutures.
The Banana SutureLasso and the nitinol wire are pulled simultaneously out from
the distal stab incisions. This delivers proximal suture through the stab incisions.
The same is done for opposite side.
While applying maximal tension across the sutures, the ankle is cycled through
dorsiflexion and plantar flexion approximately 10 times to minimize any creep
from suture. Tendon apposition should be noted (Fig. 9).
All 3 sutures are passed through Bio-SwiveLock eyelet on each side. While the
assistant holds the ankle in a plantar-flexed position, so that 2 tendon stumps

Fig. 8. Passage of the curved needle from the distal aspect of the Achilles tendon. Ideally,
the needle should pass through the stump of the tendon, one passage is medial and the
other lateral. By passing the needle through the distal stump, this may decrease the risk
of over-tightening the tendon because the tendons edges engage each other as opposed
to sliding on top of each other if the suture was placed either anterior or posterior to the
tendon.

Fig. 9. With tension placed on the distal ends of the suture and slight plantar flexion of the
limb, direct tendon apposition can be seen.

are opposed, and applies tension on opposite side sutures, the Bio-SwiveLock
anchor is inserted into the anchor hole. Opposite side anchor is inserted in the
same manner (Fig. 10).
The repair is tested by restoration of the Thompson test.
Paratenon is approximated with 2-0 Vicryl suture.
Subcutaneous tissue is approximated with 3-0 Monocryl suture.
Skin is approximated with 3-0 nylon suture (Fig. 11).

Fig. 10. Placement of the SwivelLock in the calcaneus holds the desired tension and main-
tains tendon apposition without the need knots at the level of the rupture.

Fig. 11. Final appearance of the repair with dorsiflexion pressure placed on the foot, noting
excellent final tension and stability of the construct.

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Minimallyinvasive Treatmentsofacuteachilles Tendonruptures: Milap S. Patel,, Anish R. Kadakia

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Minimallyinvasive Treatmentsofacuteachilles Tendonruptures: Milap S. Patel,, Anish R. Kadakia

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M inima lly I n vas i ve

Foot Ankle Clin N Am 24 (2019) 399–424

additionally have a detrimental effect on activities of daily living. Increased functional

RATIONALE FOR NONSURGICAL MANAGEMENT

Proponents of nonsurgical management have always cited surgical complications as

Nilsson-Helander and colleagues21 performed a randomized controlled study, which

RATIONALE FOR SURGICAL MANAGEMENT WITH MINIMALLY INVASIVE

Historically, nonsurgical management have had significantly higher rerupture rates

technique indirectly approximates ruptured tendon stumps without exposure at the

Week 0–2  Non–weight-bearing splint in place

(continued on next page)

(continued on next page)

Abbreviations: LE, lower extremity; ROM, range of motion.

AUTHORS’ PREFERRED TECHNIQUES FOR MINIMALLY INVASIVE ACHILLES REPAIR

as required. A transverse incision is another alternative; however, a Z-shaped

when visualized from medially or laterally. Occasionally, the Achilles tendon

Midsubstance Speed Bridge Repair

1. Gwynne-Jones DP, Sims M. Epidemiology and outcomes of acute achilles tendon

ruptures: a meta-analysis of randomized, controlled trials. J Bone Joint Surg Am

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Week 0–2 Non–weight-bearing splint in place