SLR - June 2020 - Mahsa Agha Jafari

Jigless Knotless Internal Brace Technique for Acute Achilles Tendon Rupture: A Case Series Study

Reference: Po-Yen Ko, Ming-Tung Huang, Chia-Lung Li, Wei-Ren Su, I-Ming Jou, Po-Ting Wu. Jigless Knotless Internal Brace Technique for Acute Achilles Tendon Rupture: A Case Series Study. Journal of Orthopaedic Surgery and Research. 2019 December 05; 14:415

Scientific Literature Review

Reviewed By: Mahsa Agha Jafari, DPM
Residency Program: Creighton University – Phoenix, AZ

Podiatric Relevance: One of the more frequent tendon ruptures encountered by a podiatrist is the rupture of the Achilles tendon. Management options vary from non-operative treatment (cast immobilization) to operative treatment, which may be either percutaneous or an open technique. Both surgical techniques have varying rates of postoperative complications, including infection, re rupture, adhesions and nerve injuries. This article presents a novel surgical technique to repair the Achilles tendon by avoiding the sural nerve and minimizing post operative complications.

Methods: This case series reviewed 10 patients treated for acute Achilles tendon rupture between 2015-2017. Inclusion criteria included a positive Thompson and a palpable defect in the Achilles tendon corresponding to rupture. Surgical procedure consisted of a 3-centimeter transverse incision made 2 cm proximal to the ruptured end. The proximal stump was pulled out through the transverse incision and Krackow locking loops were used on both sides of the soleus. Percutaneous suture was crisscrossed through the distal stump. The end of the distal stump suture was subcutaneously passed through the transverse incision and looped through the proximal stump Krackow locking loop. Two 0.5-centimeter long vertical incisions were made on the posterior calcaneal tuberosity, and arthroscopic suture passer was passed from the vertical incision to the transverse incision; ipsilateral Krackow suture end and contralateral crisscross suture end were passed down to the distal mini-vertical incision and sutures were seated at the posterior calcaneal tuberosity with two 4.5-millimeter suture anchors. Patients were advised to walk full weight-bearing with crutches and shoes with an added heel wedge immediately post-surgery.

Results: Average length of surgery was 22 minutes and transverse incision averaged 6.3 centimeters proximal to the calcaneal tuberosity. No post operative complications including adhesions, infection, sural nerve injuries and re-ruptures were noted. At one year post-op, all 10 patients scored 100 on AOFAS scale.

Conclusions: Previous studies have reported comparable results of tensile strength between percutaneous and open repair of Achilles tendon ruptures. Although, the incidence of sural nerve injury is higher with minimally invasive techniques. Cadaveric studies have reported that the sural nerve crosses the lateral border of the Achilles tendon 8.28–8.96 centimeters proximal to the calcaneal tuberosity. This study suggests sural nerve injury can be avoided if incision is made less than 8 centimeters proximal to the calcaneal tuberosity. This surgical technique for percutaneous Achilles tendon rupture repair presented in this study had satisfactory functional outcomes without any significant postoperative complications, including sural nerve injury. 

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