Limited Incision Achilles Repair—Two Techniques

Bruce Cohen

Emilio Wagner

INTRODUCTION

Achilles tendon ruptures are common in the elite and recreational athlete and most often occur in the noninsertional region of the tendon.¹^, ²^, ³ These injuries typically occur in middle-aged “weekend warriors.” The treatment of these injuries has led to much controversy in the literature recently. The previous “gold standard” of open repair has come under much scrutiny due to concerns of significant complication rates including wound healing difficulties and infection.⁴^, ⁵^, ⁶^, ⁷^, ⁸

In 1977 Ma and Griffith described a percutaneous approach for acute Achilles tendon repair. This involved sutures passed outside of the tendon sheath percutaneously. While their clinical results were reasonably good they were noted to have a number of patients with sural nerve injury or nerve entrapment as well as tendon reruptures in their initial series.⁹ Complications in a randomized trial of minimally invasive Achilles tendon rupture repairs published in 2001 included wound puckering, adhesions, reruptures, and sural nerve paresthesia.¹⁰ Assal et al.¹¹ in 2002 described the use of a new disposable jig for limited incision repairs that allowed the placement of sutures within the tendon inside the tendon sheath. In this series there were no infections, wound complications, or sural nerve injuries. The authors did report three early reruptures in their series.

The discussion of the most appropriate treatment for the acute Achilles rupture includes nonoperative treatment, standard open Achilles repair, and recently popularized minimal incision techniques.¹²^, ¹³ Khan in 2005 performed a meta-analysis which included 12 clinical trials and over 800 patients. The rerupture risk was lower in the operative group while the complication rate was significantly higher in the open repair group. The percutaneous group fared better with respect to lower incidence of complications.¹⁴^, ¹⁵ Cetti¹⁶ in 1997 performed a randomized study comparing operative versus nonoperative treatment and found a significant difference in rerupture rates between the two groups. In 2010 Chiodo et al.¹⁷^, ¹⁸ presented the results of the AAOS Clinical Guideline Committee which concluded that nonoperative treatment had lower complication rates and with moderate evidence supporting that the limited incision techniques had advantages over the open technique with respect to wound and overall complication rates. Recent published reports comparing nonoperative management to operative treatment have demonstrated no significant difference between the groups with respect to rerupture but there may be a trend toward better clinical outcomes in the operative group. The rerupture rates have not been shown to be statistically different between the groups but this may be due to the limited power of the studies. The important factor in the nonoperative treatment has been shown to involve early mobilization and weight bearing.¹⁰^, ¹²^, ¹⁹^, ²⁰^, ²¹^, ²²^, ²³

Recent literature evaluating the strength of the limited incision repairs has compared these techniques to standard open repairs. The limited incision repairs were noted to have excellent strength and in some series are superior in strength and load to failure versus standard open techniques.²⁴^, ²⁵^, ²⁶^, ²⁷ Clinical results have not demonstrated any difference in rupture rates between standard repairs and limited incision approaches.¹⁰^, ²⁰

Jig (Intrasheath) Technique

Indications

The goals of surgical treatment of Achilles tendon ruptures include the restoration of muscle-tendon integrity, restoring the strength of the repaired tendon, and minimizing the rerupture rate. These all need to be accomplished while avoiding surgical complications. The indications for limited incision repairs take into account the patient’s age, medical comorbidities as well as their activity level for sports and recreational activities. This technique is indicated for acute midsubstance ruptures. It is contraindicated in proximal ruptures, insertional ruptures or avulsions, or subacute presentation (greater than 2 to 3 weeks post injury).

Patient Positioning

The patient is positioned prone under general anesthesia with supplemental popliteal block and possible indwelling popliteal catheters for postoperative analgesia. A thigh
tourniquet is used and all appropriate pressure points are well padded.

Surgical Approaches

The surgical approach includes a transverse or longitudinal incision at the level of the rerupture. The transverse approach allows better capture of the tendon edges and easier placement of the Achilles jig. The potential downside of this approach is if needed to convert to open repair, although rarely necessary, an S-shaped incision results.

The paratenon is opened and the proximal tendon is grasped with an Allis clamp (Fig. 4-1) and the jig is passed capturing the tendon proximally (Fig. 4-2). The sutures are passed in sequence as per the numbered holes on the jig. It is important to push the tendon down manually as the sutures are passed to maximize the tendon purchase. It is also important to avoid levering with the guide, which may cause the needles to miss the internal arms of the device. The suture technique allows the placement of two transverse sutures followed by two obliquely placed looped sutures. The looped sutures allow the creation of a locked stitch which increases the strength and tendon purchase (Fig. 4-3A,B). A third transverse suture is passed. The guide allows the placement of a second locked suture through the same technique, which we have not found to be necessary. The jig is then withdrawn from the wound leaving the sutures within the tendon sheath (Figs. 4-4A,B and 4-5). Each suture is checked for purchase. If a suture pulls out then the guide is reinserted and that suture is passed again. The identical technique is used for the distal portion of the tendon.

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