September 16, 2019
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Minimally invasive repairs are used for midsubstance Achilles tendon ruptures

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Acute midsubstance Achilles tendon ruptures are an increasingly common injury among athletic patients that can lead to significant functional limitations and decreased quality of life. Management of these injuries remains controversial with no consensus in the literature regarding the role of surgical treatment or optimal repair technique. Recent literature has shown that surgical repair can result in faster and a 16% to 24% increased return of calf muscle strength, decreased tendon elongation and improved physical function and pain scores compared to nonoperative functional rehabilitation. Various surgical techniques have been described for midsubstance Achilles ruptures including open repair with Krackow locking sutures, limited incision repair using suture-passing jigs and percutaneous repair. The overall goal of minimally invasive Achilles repair techniques is to maximize the functional benefits of direct tendon repair while minimizing postoperative complications, such as delayed wound healing and infection.

We describe two minimally invasive Achilles tendon repair techniques. The Percutaneous Achilles Repair System or PARS (Arthrex) technique is described in this article. In the October 2019 issue of Orthopedics Today, we all describe the Achilles Midsubstance SpeedBridge (Arthrex) technique, both of which use a small, 2-cm incision and reusable jig to percutaneously pass sutures through the proximal Achilles tendon stump. The percutaneous PARS technique repeats suture passing using the jig for the distal Achilles tendon followed by knot tying.

Figure 1. The percutaneous reusable metal jig is shown. Its inner prongs widen and narrow using a center turn wheel. Numbered side holes permit needle and suture passing (a). A 2-cm transverse or vertical skin incision is marked just proximal to the level of the tendon rupture to ensure adequate control of the proximal stump (b). Once the paratenon is incised, there is typically hematoma identified at the rupture site (c). The proximal tendon stump is secured with a clamp and gently pulled distally out of the wound (d) followed by insertion of the PARS jig within the paratenon (e). The jig should be centered and glide smoothly against the sides of the Achilles tendon for correct placement.
Figure 2. Suture-passing needles are placed through the jig followed by repair or tape sutures from proximal to distal until all sutures are passed. Five to seven sutures are passed depending on the number of desired locking sutures (a). The jig is removed from the wound and suture pairs are separated (b). Sutures are looped and passed to create locking sutures (c).

Source: Andrew R. Hsu, MD

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In 2015, Andrew R. Hsu, MD, and colleagues reported that, in a review of 270 surgically treated Achilles tendon ruptures, of which 101 were repaired with the percutaneous technique and 169 were repaired open, the percutaneous group had shorter surgical times and a greater number of patients who returned to baseline physical activities by 5 months compared to the open repair group. The overall postoperative complication rate was 5% in the percutaneous group and 11% in the open group. There were no cases of sural neuritis or deep infection that required re-operation in the percutaneous group. Results for 34 patients treated with the Achilles midsubstance technique included an average return to baseline activities of 18.2 weeks (range 9 weeks to 26 weeks) with no wound complications, nerve injuries or re-ruptures. Patients were allowed to begin range of motion and weight-bearing immediately after surgery. Physical therapy began after 1 week to 2 weeks.

OR setup, approach

Patients are positioned prone with a thigh tourniquet and their arms at less than 90° abduction. Feet are placed slightly hanging off the end of the bed with a bump beneath the operative side ankle to adjust the plantar flexion and Achilles tension and avoid interference with the contralateral leg. The operative leg should be in neutral rotation to allow subsequent central positioning of the PARS jig. After prepping and draping, the extremity is exsanguinated and the tourniquet is inflated.

The defect within the Achilles tendon is palpated. A 2-cm transverse or vertical incision is marked just proximal to the defect in the center of the Achilles tendon (Figure 1). Placing the incision just proximal to the rupture site ensures proper visualization and control of the proximal Achilles tendon stump, which can be retracted proximally into the calf. The distal stump can be brought into the incision by plantar flexing the ankle. A transverse incision follows the natural skin creases in the back of the ankle and allows for percutaneous jig insertion with minimal paratenon disruption. A vertical incision can be used and extended in cases of tendinosis, calcifications or delayed presentation, but it requires increased paratenon and soft tissue disruption.

The skin and soft tissues are incised using a “no-touch” technique without pickups. Dissection is carefully carried down to the paratenon, which is then sharply incised. Preservation of the paratenon helps minimize disruption to the vascular supply of the tendon and allows for repair at the end of the case. The sural nerve is not typically visualized in the operative field, but if it is, it can be dissected out and retracted out of the way using a vessel loop.

An index finger or freer can be used within the wound to confirm that the center of the rupture has been located. An Allis clamp is then inserted into the wound and the proximal tendon stump is secured and pulled through the wound 1 cm to 2 cm. A freer is run along the dorsal aspect of the proximal tendon to release potential adhesions that may limit distal excursion. Dissection is avoided along the ventral aspect of the tendon to preserve native tendon blood supply.

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Proximal jig insertion

The percutaneous jig is inserted into the wound with the inner prongs in the narrowest position possible while gently placing traction on the proximal tendon stump with a clamp. The center turn wheel is used to widen the inner prongs so that they slide along the sides of the tendon in the paratenon. Proper jig placement should allow the jig to slide along the tendon with minimal resistance. Palpate the proximal tendon under the skin to check that the tendon is centered within the prongs of the jig. The most common error is to insert the jig too deep, which causes subsequent needles and sutures to miss the tendon and pull through.

Once it is properly located, keep the jig centered and stabilized so that it does not veer medially or laterally. During suture passing, all the needles (1.6 mm) with Nitinol loops are first used unloaded without suture. The first two needles are inserted into their respective numbered holes through the tendon and then through the opposite side of the jig (Figure 2). Each needle is checked to make sure it does not pass outside of the jig. Placement of two needles within the jig and tendon at all times during suture passing helps stabilize the jig and avoids adjacent suture piercing with the subsequent needle.

Then, #2 FiberWire suture (Arthrex) or SutureTape suture (Arthrex) is passed through the jig using the needle suture passer and made even in length on both sides. SutureTape has a broader, flatter surface to increase the contact surface area between the suture and tendon and reduce any suture cutting through frayed tendon. The colors of the sutures are not as important as the order in which they are placed. An assistant can write down the colors and order of the sutures passed, as needed. The two central sutures — #3 and #4 — have one looped end and one end with a tail. They are passed in an oblique, crossing pattern. These sutures create locking sutures on either side of the tendon. Holes #6 and #7 can be used if a second locking suture is needed.

Jig removal, suture management

After all sutures are passed, the turn wheel is used to narrow the inner prongs as controlled tension is applied to the jig to remove it. All the sutures from both sides of the tendon are removed from the wound. Before the jig is completely removed, a hemostat is used through each loop of sutures to guide them out of the wound. Both pairs of sutures are tested and pulled distally to ensure adequate proximal fixation has been achieved.

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If any or all of the sutures pull out of the tendon, this indicates the tendon was not centered in the jig or the jig was placed too deep or not proximal enough along the tendon during suture passing. If this occurs, remove the sutures and repeat the previous steps paying attention to tendon positioning within the jig. Do not to extend the incision longitudinally on either end of a transverse incision as this may lead to wound healing complications. Once proximal fixation is achieved, the sutures on each side of the tendon should be neatly spread apart in the following order from proximal to distal: first suture; second suture; looped, green striped suture (third); tail of the green striped suture (fourth); and fifth suture. The second suture on both sides is looped around the two green striped sutures and back proximally through the looped end of the green striped suture.

The green-striped suture tail is pulled through the tendon onto the opposite side to create a locking suture on both sides of the tendon. In the end, there are two non-locking sutures and one locking suture on either side of the tendon. Each pair of sutures is individually pulled distally to confirm fixation and remove creep from the sutures. A hemostat is placed on each group of three sutures to keep these out of the way during distal tendon preparation.

For distal tendon preparation using this technique, repeat the above steps. Secure the distal tendon stump with an Allis clamp and deliver it out of the wound while inserting the jig (Figure 3). The jig should be inserted as distal as possible to the Achilles insertion to ensure that all sutures are passed through the tendon. Suture passing, jig removal and creation of locking sutures follow the previously outlined steps. Test and pull on each pair of sutures to ensure that adequate distal tendon fixation was achieved.

Figure 3. The jig is inserted distally. The suture passing steps are repeated moving distal to proximal (a). The jig is removed and sutures are passed. Sutures are tied with the ankle in maximum plantar flexion ensuring opposing tension is held when tying the non-locking sutures (b). Paratenon and subcutaneous tissues are meticulously closed in a layered fashion followed by skin closure. A soft dressing is placed over the wound followed by a posterior mold non-weight-bearing splint with the ankle in resting plantar flexion, or a non-weight-bearing tall CAM boot with heel lifts can be used (c).
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Achilles tensioning, suture tying

The ankle should be placed and held in maximum plantar flexion during suture tying for a secure repair. We have never found the Achilles tendon repair to be too tight when using the percutaneous technique. The tendon will always gradually stretch out during weight-bearing and physical therapy. When tying non-locking sutures, have an assistant hold tension on the opposite side as the suture will continue to slide through the tendon with increasing force applied to the suture during knot tying. During tying, pull out any remaining slack from the sutures before securing them with five to six knots. After each suture is tied, cut it above the knot and away from the other sutures to avoid tangling.

After the sutures are tied, the ankle should be plantar flexed with improved resting tension. After wound irrigation, ensure the suture knots are tucked ventrally into the wound and do not protrude into the subcutaneous tissue. Residual strands of tendon should be sharply debrided and tucked within the wound for adequate paratenon closure. Absorbable sutures are used to close the paratenon and subcutaneous tissues. Nylon sutures are used for skin closure.

Disclosures: Anderson reports he is a paid consultant for Amniox, Artelon, Arthrex, Bioventus, DJO, NuVasive, Wright Medical Technology and Zimmer Biomet. Berlet reports he is a paid consultant for Artelon, DJO, Wright Medical Technology and Zimmer Biomet. Hsu reports he is a paid consultant for Arthrex.