Midsubstance ruptures of the Achilles tendon approximately 2 to 6 cm proximal to its insertion on the calcaneus are an increasingly common injury among athletic patients 30 to 50 years old, with more than 50% of all injuries occurring during recreational basketball.1,2 Insertional Achilles tendon ruptures and sleeve avulsions are less common injuries and occur when the distal tendon pulls off of its insertion on the calcaneal tuberosity, often with a small attached bony fragment. Both midsubstance and insertional ruptures tend to occur at a higher rate when patients are deconditioned and try to suddenly perform explosive push-off and impact activities. Patients with a history of insertional Achilles tendinitis, retrocalcaneal bursitis, and Haglund syndrome are at increased risk for insertional ruptures during overuse activities.3–5
The management of acute midsubstance Achilles ruptures remains controversial, with no consensus in the literature regarding nonoperative treatment, surgical repair, and optimal repair technique.1,6–10 However, insertional ruptures generally require early tendon repair to bone to permit proper healing and restore tendon function.3,5,11,12 Complex combined ruptures of the insertion and midsubstance of the Achilles tendon are rare injuries that typically occur in healthy, active patients with a history of insertional Achilles tendinitis. In these injuries, a complex longitudinal oblique tear originates distally, avulses off of a fragment of posterior bone, and propagates proximally into a complete tear. There is little in the literature describing these challenging injuries and their appropriate surgical management.
In this report, the author describes a novel technique for repair of combined insertional and midsubstance Achilles ruptures that uses a proximal percutaneous technique and distal knotless repair using anchors. This technique avoids the need for extensive proximal soft tissue dissection and addresses both rupture locations to restore tendon length with direct fixation of tendon to bone.
Primary indications for acute combined Achilles tendon repair include healthy, physically active patients with ruptures who present within 4 weeks from the time of injury to ensure that tendon ends can be mobilized and repaired to restore appropriate length and tension. Most patients with insertional ruptures have preexisting symptoms of insertional Achilles tendinitis and Haglund syndrome.5,12 Combined midsubstance and insertional Achilles tendon ruptures can be difficult to diagnose on clinical examination alone because there is often not an obvious palpable defect or bony avulsion fragment along the course of the tendon. In addition, the results of a Thompson test can be misleading due to partially intact fibers along the medial and/or lateral aspects of the tendon.
A preoperative lateral radiograph often shows a discrete bony fragment with irregular edges that has pulled off of the Achilles insertion adjacent to a proximal soft tissue defect within the mid-substance of the Achilles tendon (Figure 1). A Haglund deformity is often present, which is thought to exacerbate breakdown of the Achilles insertion due to mechanical bony impingement. Magnetic resonance imaging is often required to confirm the presence of a combined Achilles rupture and better delineate the mid-substance and insertional areas of rupture along the medial and lateral sides of the tendon (Figure 2). Sequential sagittal magnetic resonance imaging cuts typically show areas of intact insertional tendon fibers mixed with local edema along with midsubstance tendon discontinuity, which is confirmed on sequential coronal cuts.
Lateral ankle radiograph of a 28-year-old healthy, active man with a history of insertional Achilles tendinitis symptoms who felt a pop in the back of his ankle while jumping during basketball 3½ weeks before presentation. The radiograph shows a 1-cm fragment of bone (solid red arrow) that has avulsed off of the Achilles insertion adjacent to a proximal soft tissue defect in the midsubstance of the Achilles tendon (dashed yellow arrow). It also shows a Haglund deformity and preexisting calcific spurs over the Achilles insertion.
Sagittal magnetic resonance imaging cut at the midportion of the Achilles tendon showing a complex longitudinal oblique tear that originated distally, avulsed a piece of posterior bone, and propagated proximally into a complete tear. There are multiple areas of midsubstance and insertional Achilles disruption with surrounding edema (A). Sequential sagittal magnetic resonance imaging cut just lateral to midline showing lack of tendon continuity to the Achilles insertion (B). Coronal magnetic resonance imaging cut showing a complex Achilles rupture with combined midsubstance and insertional components (C).
A relative contraindication to primary Achilles repair is delayed presentation (>4 weeks), which may require a proximal open gastrocnemius V-Y lengthening, central slip turndown, or other procedures. Additional relative contraindications include patients with chronic Achilles tendinopathy, which may require flexor hallucis longus tendon transfer; significant smoking history; and medical comorbidities that prohibit surgical intervention.
Surgery is typically performed under general anesthesia with a regional popliteal-saphenous block. Patients are positioned prone with chest rolls and kneepads and with the arms at less than 90° of abduction to prevent brachial plexus traction injury. A thigh tourniquet is placed on the operative extremity and both feet are placed hanging slightly off of the end of the operating table. A small bump is placed underneath the anterior ankle to adjust the degree of ankle plantarflexion and Achilles tension during the case and avoid interference of the contralateral ankle.
If the individual surgeon desires biologic augmentation of the Achilles repair, 60 cc of bone marrow aspirate can be obtained from the posterior iliac crest at the beginning of the case using a sharp trochar and two 30-cc syringes (Figure 3). The 60 cc of bone marrow aspirate is spun down during 20 minutes to form approximately 4 cc of bone marrow concentrate that can be applied over the Achilles repair construct as needed.
Biologic augmentation for the Achilles repair can be obtained as needed at the beginning of the case by extracting 60 cc of bone marrow aspirate from the posterior iliac crest and spinning it down to form 4 cc of bone marrow concentrate (Angel System; Arthrex, Inc, Naples, Florida) (A). A longitudinal incision is made over the Achilles tendon with preservation of the paratenon, and the bony avulsion fragment is identified in the proximal aspect of the wound (arrow) (B). The 1×1-cm fragment (C) is sharply excised, with complete removal confirmed on radiograph (D).
A longitudinal central incision is made over the Achilles tendon, extending down to the distal aspect of the Achilles insertion. Skin is incised, and the paratenon is carefully dissected and preserved for later repair. There is often a visible rent with hematoma in the midsubstance of the Achilles tendon where the insertional bony fragment is located. The bony fragment is sharply excised, with complete removal confirmed on radiograph. If the fragment is located more proximal to the incision, a dual vertical incision approach can be used with a 3- to 4-cm soft tissue bridge between incisions (Tables 1–2).
After fragment removal, a central split is made along the distal aspect of the tendon to expose the Haglund deformity and Achilles insertion. Sharp dissection is performed along the medial and lateral aspects of the Achilles insertion to provide adequate exposure prior to any bony resection (Figure 4). The Haglund deformity and insertional spurs are removed using a saw blade on power, which is followed by a power rasp to smooth down all of the bony edges.
A central split is made in the distal aspect of the Achilles to expose the Haglund deformity and Achilles insertion (A). These are then removed using a small saw blade on power (B). The bony edges are smoothed down using a power rasp (C), which is followed by marking the locations of the 4 planned anchor sites along the proximal and distal aspects of the calcaneal tuberosity (D). Each anchor site is drilled with a 3.5-mm drill (E). This is followed by a hand tap for a 4.75-mm anchor, ensuring that the anchor sites do not converge into each other (F).
Once bony preparation of the insertional aspect of the Achilles tendon is complete, the planned anchor sites for the combined Achilles repair are marked on bone, ensuring that there is adequate space in between each anchor so that they do not converge or skive off of the edges of bone. Using lateral radiographs, each anchor site is drilled on power with a 3.5-mm drill and tapped by hand for a 4.75-mm anchor. Radiographs are carefully analyzed to ensure that the drill holes do not converge and enter perpendicular to the bony surfaces proximal and distal.
Attention is then turned back to the proximal aspect of the Achilles tendon to the area of midsubstance rupture. Hematoma and early scar tissue, which should be sharply debrided back to healthy, striated tendon edges, are often present in the area of midsubstance rupture (Figure 5). In cases of delayed presentation (3 to 4 weeks), the amount of tendon adhesions and scar tissue can be significant and require formal excision of up to 2 cm of tissue at the midsubstance rupture. The author has not found any problems with direct repair of tendon ends with up to a 2-cm tendon defect. If the defect is greater than 2 cm, a proximal mini-incision gastrocnemius recession may be required.
The midsubstance Achilles rupture area is sharply debrided of all remaining unhealthy tissue back to normal striated tendon ends, leaving up to a 2-cm defect in the tendon (A). The PARS jig (Arthrex, Inc, Naples, Florida) is passed along the proximal Achilles tendon with passage of color-coded sutures (B). The jig and sutures are removed. This is followed by suture passing to create 2 non-locking sutures and 1 locking suture for proximal Achilles tendon control. The central split in the Achilles tendon is repaired using absorbable sutures, and each pair of sutures is then passed through the distal aspect of the tendon using a suture passer (C). Each pair of proximal sutures is passed through the eyelet of a 4.75-mm SwiveLock anchor (Arthrex, Inc) already preloaded with 2 FiberTape sutures (Arthrex, Inc) (D). With the ankle in plantarflexion, the proximal 2 anchors are inserted to secure the midsubstance Achilles repair to bone (E).
Rather than continuing to extend the incision proximal to expose the proximal aspect of the Achilles tendon to place Krackow locking sutures, the percutaneous jig is inserted into the wound with the inner prongs placed along the medial and lateral sides of the tendon.4 The center turn wheel is used to widen the inner prongs as the jig is slid proximal. Proper jig placement should allow for smooth jig movement with little resistance. The proximal tendon can be palpated within the prongs of the jig to ensure that the tendon is centered within the jig. A common error is placing the jig too deep, which will cause the subsequent needles and sutures to miss the tendon and pull out.
With the jig in a central position in neutral rotation, needles with Nitinol loops are passed through the numbered holes along the side of the jig. This is followed by passage of color-coded 1.3-mm sutures. The jig and sutures are removed through the incision, and the sutures are then passed to form 2 non-locking sutures and 1 locking suture with proximal fixation of the Achilles tendon.
The central split in the distal aspect of the Achilles tendon is repaired using an absorbable running suture to better visualize the normal contour and insertion of the Achilles tendon.
A suture passer is used through the distal central aspect of the tendon to retrieve the proximal sutures on the medial and lateral sides. Passage of the suture passer is facilitated by tactile feedback as it is passed through tendon. The surgeon's non-dominant thumb is placed directly against the distal tendon while the dominant hand grasps the suture passer with the thumb near the tip. As the suture passer is advanced proximally, the surgeon can feel the tip advance through mild resistance as it moves through tendon. In addition, the tip of the suture passer can be confirmed to be in the center of the tendon through direct visual inspection through the wound.
Each pair of sutures on the medial and lateral sides is placed under maximal tension and cycled multiple times (5 to 10) to remove any residual creep in the sutures proximally. The ankle is plantarflexed to appropriately tension the Achilles tendon relative to the contralateral limb and then held in place by an assistant. At the same time, the assistant holds tension on the opposite pair of sutures to ensure that tendon length and tension do not change prior to anchor insertion. The rupture site can be palpated and visualized to confirm that no residual gap or excessive overlap of the tendon ends is present. If the tendon ends cannot be adequately brought together, a separate proximal 2- to 3-cm mini-incision can be made over the medial calf to perform a gastrocnemius recession.
Then, each pair of sutures is passed through the eyelet of a 4.75-mm anchor already preloaded with 2 flat Fiber-Tape sutures (Arthrex, Inc, Naples, Florida). Each anchor is malleted into the proximal drill holes. This is followed by hand tightening until the anchor is flush with bone. The position of the drill holes can be rechecked with a K-wire prior to anchor insertion, as their relative position will have changed with the ankle in a plantarflexed position. The remaining suture threads are cut flush with bone while leaving the flat FiberTape limbs intact. Once both anchors are inserted, the midsubstance Achilles repair portion of the procedure is complete with restoration of tendon length and tension.
The needles attached to the flat FiberTape limbs are passed through a 1-cm symmetrical bite of Achilles tendon on the medial and lateral sides. The needles are cut off of the sutures and then 1 tail from each anchor is passed through the eyelet of a 4.75-mm anchor. The 2 anchors are then individually inserted into the prepared distal drill holes on the medial and lateral sides of the Achilles insertion until they are flush with bone. The sutures are cut to create a final knotless construct that has a double-row pattern to maximize surface area contact of the Achilles insertion onto bone (Figure 6).
The free tails of the remaining sutures are cut flush with the anchors, leaving the FiberTape sutures (Arthrex, Inc, Naples, Florida) intact. The FiberTape sutures are passed through a symmetric 1-cm bite of distal Achilles tendon on the medial and lateral sides using the attached needles. The needles are then removed and 1 tail from each anchor is passed through the eyelet of a 4.75-mm anchor and then inserted into the distal drill holes. The final repair construct has a knotless double-row pattern (A). Bone marrow concentrate can then be sprayed over the midsubstance and insertional Achilles repair sites using a spray nozzle (B). The bone marrow concentrate layer is left on the repair site (C). This is followed by careful paratenon, subcutaneous tissue, and skin closure (D). Patients are then placed in a soft dressing followed by a resting equinus splint or tall controlled ankle motion boot with 2-cm heel lifts for the first 2 weeks postoperatively (E).
The midsubstance repair site can be reinforced with absorbable sutures in a figure-of-8 pattern as needed. If biologic augmentation is desired, the bone marrow concentrate obtained at the beginning of the case can be applied to the tendon repair sites using a spray nozzle or mixed with vancomycin powder for antibiotic prophylaxis to form a putty material. The viscosity of the bone marrow concentrate can be adjusted using different mixing ratios of thrombin.
The paratenon and subcutaneous tissues are repaired with absorbable sutures followed by 3-0 nylon sutures for skin. The patient is then placed in a soft dressing followed by a non–weight-bearing resting equinus splint or tall controlled ankle motion boot with 2-cm heel lifts for the first 2 weeks postoperatively.
0 to 2 Weeks. Patients are immobilized in a non–weight-bearing splint or tall controlled ankle motion boot with 2-cm heel lifts. Sutures are removed at 2 to 4 weeks depending on the degree of skin and soft tissue healing.
2 to 4 Weeks. Patients are made partial weight bearing in a tall controlled ankle motion boot with 2-cm heel lifts working on active ankle plantarflexion exercises. Heel lifts are decreased by 1 cm every week.
4 to 6 Weeks. Patients are weight bearing as tolerated in a tall controlled ankle motion boot without heel lifts, beginning physical therapy at 6 weeks postoperatively.
6 to 10 Weeks. Patients are weight bearing as tolerated in a regular athletic shoe, continuing to work with physical therapy on range of motion and strengthening exercises. Impact activities are avoided.
10 to 14 Weeks. Patients begin progressively increasing impact activities with a return to regular activities and athletics as tolerated.
The primary reported complication associated with mid-substance and insertional Achilles tendon repairs is wound healing problems, which can lead to superficial and deep infection requiring antibiotics and reoperation.5,10,12–14 Therefore, there is now a trend toward using limited incision repairs for Achilles tendon ruptures to improve recovery time and functional outcomes and lower the incidence of postoperative complications.1,4,15–18 One of the advantages of the current author's dual repair technique is that it allows the surgeon to gain proximal control of the Achilles tendon using a percutaneous jig rather than extending the incision proximal by an additional 3 to 6 cm.
With the surgical technique described in this report, the author has found that additional potential complications are iatrogenic and include anchor misplacement in a converging fashion or along the edges of bone causing skiving, failure to fully seat the anchors flush in bone, and improper tensioning of the midsubstance and insertional repair sites. All of these potential technical complications can be avoided by following careful technique, especially during anchor insertion. If anchors are misplaced or maltensioned, they can be removed, adjusted, and reinserted during the procedure to prevent postoperative complications.
Results and Discussion
In a preliminary series of 3 patients treated using a combined insertional and midsubstance Achilles knotless repair technique, the author has had no cases of wound breakdown, superficial or deep infection, sural nerve injury, or re-rupture. All patients were physically healthy and active and had a history of insertional Achilles tendinitis symptoms prior to their acute ruptures. Patients were able to return to baseline physical activities by an average of 5 to 6 months postoperatively. The author has not found any evidence of decreased clinical or functional outcomes compared with patients treated for isolated insertional or mid-substance Achilles ruptures.
A variety of surgical techniques exist for open midsubstance Achilles repair, including Krackow locking sutures, percutaneous repair, and limited incision repair using suture-passing jigs. In a single-center comparative review of 270 surgically treated Achilles tendon ruptures (101 percutaneous, 169 traditional open repair), Hsu et al1 found that the percutaneous group had significantly shorter surgical times and a higher number of patients returning to baseline physical activities by 5 months compared with the open repair group. The overall percutaneous postoperative complication rate was 5%, while the open complication rate was 11%. There were no cases of sural neuritis or deep infection requiring reoperation in the percutaneous group. With modification of the percutaneous technique to create a knotless construct with direct fixation to bone,4 34 patients returned to baseline activities at an average of 18.2 weeks (range, 9–26 weeks) with no wound complications, nerve injuries, or re-ruptures.19
Insertional Achilles ruptures and sleeve avulsions often require more extensive soft tissue dissection and bony resection during repair to address the causes of insertional diseases in addition to the ruptured tendon.3,5,11,12 Commonly employed repair techniques involve a longitudinal posterior incision, retrocalcaneal bursectomy, Haglund and insertional calcific spur excision, removal of diseased tendon and bony fragments, and transosseous bone tunnels or use of 3.5-, 4.5-, or 5.5-mm suture anchors.3,5,11,12,20 In a series of 11 patients with Achilles tendon sleeve avulsions, Huh et al12 reported that 72.7% of patients had preexisting symptoms of insertional Achilles disease and 90.9% of patients had concurrent Haglund deformity with tendinopathy intraoperatively. At an average 3.2-year follow-up, patients had an average American Orthopaedic Foot & Ankle Society score of 92.8 and visual analog scale score of 0.9 with 1 complication stemming from delayed wound healing.
In a recent larger series of patients with insertional Achilles ruptures that included 16 patients from the general population and 12 professional athletes, Schipper et al5 reported good clinical outcomes at an average 8.1-year follow-up using both transosseus bone tunnel and suture anchor techniques. The final median Foot and Ankle Ability Measure Activities of Daily Living score was 100 (range, 42.9–106) and the median Foot and Ankle Ability Measure Sports score was 100 (range, 7.1–103.6). In the cohort of professional athletes, preceding insertional Achilles symptoms were present in 91.7% for more than 9 months before rupture. All athletes returned to play an average of 13.4 months after surgical repair. Overall, there were no re-ruptures or nerve injuries, but 2 patients required operative irrigation and debridement for infection and 1 athlete had a wound complication requiring a split-thickness skin graft.
Using traditional open repair techniques, management of combined insertional and midsubstance Achilles ruptures would involve extensive posterior soft tissue dissection with Krackow locking sutures across the midsubstance rupture and suture anchors for distal tendon fixation. Disadvantages of this repair construct include the degree of proximal dissection required and the lack of strong tendon–bone fixation because the proximal tendon stump is repaired with suture to an already compromised distal stump.
In general, combined insertional and midsubstance Achilles ruptures are rare injuries that require further research regarding incidence, patient demographics, and clinical and functional outcomes. Although these injuries can be challenging to treat surgically, the author has found that this knotless technique using a proximal percutaneous suture-passing jig in conjunction with a distal double-row anchor repair allows for decreased soft tissue dissection, reliably restores musculotendinous length, and provides strong tendon–bone fixation to permit early mobilization and functional recovery.
Complex combined insertional and midsubstance Achilles ruptures are rare injuries that require a thorough patient history, clinical examination, and review of preoperative radiographs and magnetic resonance imaging. There is often a portion of the Achilles insertion attached to a small bony fragment that is pulled off of the calcaneal tuberosity along with a more proximal partial or complete midsubstance rupture. Successful surgical treatment involves prompt recognition of the injury pattern and comprehensive repair of all the tendon and bony components of the injury. Dual insertional and midsubstance repair using a proximal percutaneous technique with distal knotless anchors can be used to restore tendon length, tension, and fixation to bone.
- Hsu AR, Jones CP, Cohen BE, Davis WH, Ellington JK, Anderson RB. Clinical outcomes and complications of percutaneous Achilles repair system versus open technique for acute Achilles tendon ruptures. Foot Ankle Int. 2015;36(11):1279–1286. doi:10.1177/1071100715589632 [CrossRef]
- Raikin SM, Garras DN, Krapchev PV. Achilles tendon injuries in a United States population. Foot Ankle Int. 2013;34(4):475–480. doi:10.1177/1071100713477621 [CrossRef]
- Bibbo C, Anderson RB, Davis WH, Agnone M. Repair of the Achilles tendon sleeve avulsion: quantitative and functional evaluation of a transcalcaneal suture technique. Foot Ankle Int. 2003;24(7):539–544.
- Hsu AR. Limited-incision knotless Achilles tendon repair. Am J Orthop (Belle Mead NJ). 2016;45(7):E487–E492.
- Schipper ON, Anderson RB, Cohen BE. Outcomes after primary repair of insertional ruptures of the Achilles tendon. Foot Ankle Int. 2018;39(6):664–668. doi:10.1177/1071100718758257 [CrossRef]
- Chiodo CP, Glazebrook M, Bluman EM, et al. American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture. J Bone Joint Surg Am. 2010;92(14):2466–2468.
- Chiodo CP, Glazebrook M, Bluman EM, et al. American Academy of Orthopaedic Surgeons. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010;18(8):503–510. doi:10.5435/00124635-201008000-00007 [CrossRef]
- Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures: a meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005;87(10):2202–2210.
- Renninger CH, Kuhn K, Fellars T, Youngblood S, Bellamy J. Operative and nonoperative management of Achilles tendon ruptures in active duty military population. Foot Ankle Int. 2016;37(3):269–273. doi:10.1177/1071100715615322 [CrossRef]
- Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010;(9):CD003674.
- Bibbo C. Technique tip: limited dual incision technique for repair of Achilles sleeve avulsions. Foot Ankle Int. 2004;25(7):513–515. doi:10.1177/107110070402500713 [CrossRef]
- Huh J, Easley ME, Nunley JA II, . Characterization and surgical management of Achilles tendon sleeve avulsions. Foot Ankle Int. 2016;37(6):596–604. doi:10.1177/1071100716629778 [CrossRef]
- McMahon SE, Smith TO, Hing CB. A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot Ankle Surg. 2011;17(4):211–217. doi:10.1016/j.fas.2010.11.001 [CrossRef]
- Nilsson-Helander K, Silbernagel KG, Thomeé R, et al. Acute Achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010;38(11):2186–2193. doi:10.1177/0363546510376052 [CrossRef]
- Tejwani NC, Lee J, Weatherall J, Sherman O. Acute Achilles tendon ruptures: a comparison of minimally invasive and open approach repairs followed by early rehabilitation. Am J Orthop (Belle Mead NJ). 2014;43(10):E221–E225.
- Metz R, Verleisdonk EJ, van der Heijden GJ, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing: a randomized controlled trial. Am J Sports Med. 2008;36(9):1688–1694. doi:10.1177/0363546508319312 [CrossRef]
- Keller A, Ortiz C, Wagner E, Wagner P, Mococain P. Mini-open tenorrhaphy of acute Achilles tendon ruptures: medium-term follow-up of 100 cases. Am J Sports Med. 2014;42(3):731–736. doi:10.1177/0363546513511418 [CrossRef]
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|Carefully review the preoperative clinical examination, radiographs, and magnetic resonance imaging to properly diagnose the presence of a combined insertional and midsubstance Achilles rupture in a timely fashion.|
|Repair of the insertional and midsubstance ruptures can be achieved through 1 longitudinal central incision extending up to the avulsed bony fragment if present or through 2 separate vertical incisions as needed depending on how proximal the midsubstance rupture is located.|
|Use a hand-held blade on power to meticulously resect the Haglund deformity and insertional calcific spurs, followed by a power rasp to smooth all bony edges.|
|Check the anchor locations using lateral radiographs to ensure they replicate the normal insertion of the Achilles tendon and do not converge.|
|Perform a mini-incision proximal gastrocnemius recession as needed if the proximal and distal tendon ends cannot be approximated end-to-end during proximal anchor insertion.|
|Check each pair of passed sutures to ensure that they are securely fixed to the proximal tendon and cycle the sutures to remove any residual creep.|
|Hold the ankle in the appropriate amount of plantarflexion to ensure end-to-end apposition of the midsubstance rupture and compare with the contralateral side as needed prior to proximal anchor insertion.|
|Carefully check the distal anchors to ensure that they are flush with bone and not prominent.|
|Avoid extensive posterior soft tissue dissection by localizing the insertional bony fragment on lateral radiograph prior to incision.|
|Carefully detach only as much of the medial and lateral aspects of the Achilles insertion as necessary to allow for adequate visualization of the Haglund deformity and insertional spurs.|
|Do not over-resect the scar and diseased tendon at the rupture sites, and do not over-resect the Haglund deformity along the posterior calcaneal tuberosity.|
|Evenly mark and space out the anchor sites in the posterior calcaneus to avoid converging drill holes or skiving off of bone.|
|Do not place the percutaneous jig too deep during needle passing, as this will cause the sutures to miss the proximal tendon and pull out of the wound.|
|Repair the central split in the distal Achilles prior to proximal anchor insertion to avoid inappropriate tensioning of the Achilles.|
|Grab symmetrical bites of the medial and lateral distal Achilles with the suture needles to avoid uneven repair of the Achilles insertion down to bone.|