Special Focus: Innovations in Foot and Ankle Sports Injury Treatment
Achilles mid-substance ruptures are common injuries, mainly affecting young, active, and male patients.1,2 Although some groups have suggested nonoperative treatment of this pathology,3 surgical treatment remains the standard of care for active patients. Nowadays, most surgeons are performing minimal invasive repair of the Achilles tendon with the objective of reducing wound complication rate,4–10 highly reported with open approaches. In contrast, accelerated rehabilitation protocols have demonstrated a reduction in working-days loss and better functional recovery.11 Nevertheless, such approach requires Achilles tendon repairs to be strong enough to be safely performed,12 to avoid re-rupture and elongation.
Several techniques have been described to percutaneously repair an Achilles tendon. In Latin America and Europe, the Dresden technique6 is one of the most commonly performed, consisting of 2 single nonlocking Fiberwire (Arthrex, Naples, FL) sutures attached to the distal stump of the Achilles tendon. This technique is performed by introducing 2 Dresden instruments through an incision about 3 cm proximal to the tendon gap. In the plane between the paratenon and the deep fascia, these instruments are driven distally, allowing catching of the distal stump with sutures, without entrapment of the sural nerve. In order to avoid nerve damage, it is of paramount importance to remain in the subfascial plane given that the sural nerve course is superficial to the deep fascia. Sutures are then recovered proximally and sutured to the proximal stump. Rupture site’s hematoma is respected, providing a biological environment that promotes healing.
Although the Dresden technique is appealing given its simplicity and reproducibility, some concern remains about repair strength and its resistance to failure, which may prevent early rehabilitation. In contrast, the Midsubstance Speedbridge (Arthrex)8 offers extremely strong fixation, prompting early rehabilitation. However, this interesting technique sacrifices biology while performing the repair through the Achilles rupture site. We believe that strong fixation, avoiding sural nerve entrapment and respecting the biologic environment are desirable features in an optimal technique. Thereby, we combined them and modified the PARS-midsubstance Achilles repair into the PARS-Dresden technique, utilizing SutureTape (Arthrex) instead of Fiberwire. Using this technique, there is no dissection or reattachment of the distal stump of the Achilles tendon. SutureTape is a flat-braided suture, stronger than the multistrand Fiberwire suture, which adds resistance to the final construct.
INDICATIONS AND CONTRAINDICATIONS
Surgical management of Achilles midsubstance ruptures is indicated in young, active patients who desire to maintain optimal function and return to their previous activity level as soon as possible. Patients presenting with ruptures within 3 weeks from injury are operated on using this technique.
Contraindications for surgical management include nonambulatory patients, poorly controlled medical comorbidities, and inability/unwillingness to participate in early rehabilitation. Smoking and diabetes are relative contraindications for the procedure and must be evaluated on a case-to-case basis.
Acute midsubstance Achilles rupture is a clinical diagnosis. Typically, patients will present acute pain in the distal lower leg, preventing them to walk and cause limping. Under physical examination, loss of the physiological flexor tone, palpable gap, and/or Thompson test are frequently encountered. In most cases, no diagnostic image is required for diagnosis. If any, a lateral radiograph of the ankle is utilized to rule out distal bony avulsion, which in this particular technique is less important given the bypassing of the distal stump. Treatment should not be deferred to obtain an ultrasound and/or MRI to confirm diagnosis.
Under spinal or general anesthesia, the patient is placed prone on the operative table. After gravity exsanguination, a thigh tourniquet is used to maintain ischemia in the operative field. Proximal and distal Achilles stumps are delimitated in the skin and a 3 cm transverse incision is marked at 3 cm proximal to the tendon gap. The incision is carried out into the deep fascia, without opening the paratenon. This structure can be easily identified as a thin layer surrounding the Achilles tendon, after blunt dissection of the deep fascia (Fig. 1). Development of the subfascial epiparatenon plane is of paramount importance to avoid entrapment of the sural nerve, as the nerve course is superficial to the deep fascia layer. Carefully, blunt dissection is performed at the medial and lateral borders of the proximal stump to properly identify the tendon width.
Afterwards, the inner arms of the PARS jig are inserted into the wound and accommodated to the tendon width by adjusting the wheel at the jig’s base (Fig. 2). The surgeon must firmly press the jig toward the Achilles tendon to ensure that enough tissue will be captured by the instrument. The outer arms of the PARS jig have 7 holes which are chronologically numbered from 1 to 7. A needle is passed through the hole number 1 and left in place during the rest of the procedure stabilizing the jig and facilitating Achilles tendon capture. Then, the PARS needle with the nitinol loop is passed through hole number 2. A blue #2 SutureTape is pulled through the leg, leaving tails on both sides of equal length. Again, the PARS needle is passed through holes 3 and 4. White and green #2 SutureTape with loops are pulled through the leg, leaving tails on both sides of equal length. The surgeon needs to be sure that 1 looped end is left on each side of the leg in order to lock 1 suture of the construct (blue SutureTape at number 2) during the operation. The PARS needle is passed through hole number 5 and the white and black #2 SutureTape is pulled through the leg, leaving tails on both sides of equal lengths. Finally, the white #2 SutureTape is pulled through the leg using the needle that was left in place at hole number 1 (Fig. 3). The jig is pulled down for removal and sutures are recovered at the wound to be organized the way they were originally placed through the PARS jig (Fig. 4). The #2 blue SutureTape is passed under the number 3 and 4 looped SutureTape and backed through the loop of the white and green looped suture at each side. By pulling on the nonlooped side (one at a time) of the number 3 and 4 white and green looped sutures, the #2 SutureTape is passed through the Achilles tendon into the other side. This step locks the blue SutureTape in place, leaving a construct with 2 transverse sutures and 1 locked at each side of the tendon.
Two stab incisions are made 2 cm apart over the calcaneus near the Achilles insertion. The 3.4 drill bit is used to prepare the hole for a 4.75 mm Swivelock (Arthrex) anchor fixation. Drilling direction should aim 45 degrees proximal and 30 degrees to midline to achieve optimal purchase (Fig. 5). Each hole must be tapered until every thread of the tap disappears into the bone, avoiding potential anchor breakage during fixation. The PARS needles are left in the prepared holes as a guide to remember tunnel direction in anticipation for final fixation (Fig. 6). A Banana SutureLasso (Arthrex) is introduced through the medial stab incision and drove through the distal medial half of the Achilles tendon into the proximal Achilles stump (Fig. 7). Sutures are loaded into the Nitinol lasso and retrieved at the incision. The same steps are realized to deliver the lateral sutures into the lateral stab incision. Making sure that maximal tension has been applied to the sutures, medial sutures are fixed into the medial tunnel using a 4.75 mm Swivelock with the foot in slight hyper plantarflexion (Fig. 8). Thereafter, the lateral sutures are fixed in a similar manner using another 4.75 mm Swivelock. Wounds are closed in a layered manner and sterile dressing applied (Fig. 9). No immobilization is used after surgery.
Eighteen patients have been operated on using the PARS-Dresden technique since March 2018. Mean age was 42 years (23 to 62 y). Patients were discharged without immobilization and authorized to weight-bear as tolerated using 2 crutches at all times for the first 4 weeks. All patients were full weight-bearing without crutches at postoperative week 5. We have not observed any rerupture or sural nerve neuritis so far.
Two patients exhibited a subtle loss of plantarflexion tone at postoperative week 1 when compared with immediate postoperative period, but remained similar to their contralateral, uninjured side. Both patients had walked without crutches in their homes and were encouraged to follow the rehabilitation protocol as prescribed. No further elongation was seen in these patients.
Patients are operated on and discharged the same day or stay overnight. No immobilization of any kind is used on these patients. All patients are authorized to weight bear on 2 crutches as tolerated. Early weight-bearing should be reconsidered if soft bone is detected during anchor placing. We do not follow-up patients using ultrasound at any time during the recovery period, unless there is clinical suspicion of re-rupture, deep infection, or unexplained pain source. Thromboprophylaxis is initated on day 1 using dabigatran for 30 days.
Dressings are changed during the first postoperative visit at 7 days and physiotherapy is started at this time. We follow a stepwise rehabilitation protocol as follows:
Week 1: Gentle mobilization and active dorsiflexion are encouraged. No passive dorsiflexion is authorized.
Week 2: Sutures are removed, and compression socks are recommended. Progressive plantarflexion exercises are started at this time.
Week 3: Crutches are progressively removed as tolerated, and plantar flexion exercises continue. Cardiovascular exercises initiated.
Week 4: Biking and passive dorsiflexion are initiated. Patients may stop using crutches if tolerated. Exercises progresses in intensity as tolerated but avoiding impact activities. Proprioceptive and gait training.
Week 8: Patients can progress to swimming or continue biking until week 12. Continue to progress range of motion, strength, and proprioception.
Week 12: Eccentric strengthening, progressive impact, loading, speed work, and plyometric training are started. Patients can progress to sports-specific activity as tolerated.
Week 20 to 24: Patients are cleared to go back to unrestricted sports if they are able to perform 20 single heel rises and have completed sport-specific protocols.
POSSIBLE CONCERNS, FUTURE OF THE TECHNIQUE
Our main concern is fixation loss in patients nonadherent with postoperative indications protocol. Initial fixation is not enough to withstand cyclic loading without crutches, as demonstrated by Clanton et al.12 In order to benefit from early weight-bearing and mobilization, patients need to understand this limitation. If proper patient counseling is not obtained, the surgeon should consider a short period of immobilization.
The presented technique is not technically demanding, is reproducible and safe in short term follow-up. More data and longer follow-up are needed to prove potential advantages over other similar techniques, like shorter recovery time, decreased re-rupture rate, less long-term tendon overlengthening and possible earlier return to sports.
Site of rupture and quality of the remaining tendon are not a concern regarding this technique. We assume that the distal portion of the Achilles tendon is degenerated and plays a crucial role in rupture generation. Moreover, this is the main reason why we have moved forward to bypass this area and reattach the proximal stump directly to the bone. Biomechanically speaking, its appealing to rely our fixation method in healthy bone rather than degenerated tissue. Compared with the Midsubstance Speedbridge technique, the main difference is that we do not open the paratenon in order to preserve rupture site hematoma and benefit from inflammatory factors liberated at the rupture site. So far, we have not used this technique for chronic Achilles tendon ruptures and a time frame of 3 weeks since the time of injury seems to be reasonable to indicate this procedure. After this period, scar tissue needs to be removed to regain normal Achilles tendon length.
Smokers and poorly controlled diabetics are overall poor surgical candidates. However, we believe this minimal invasive technique is actually better for patients with elevated comorbidities. We do not transfer the Flexor hallucis longus for those patients with nonreversible comorbidities or augment this technique when there is a poor distal stump due to age or pathophysiology. Our rationale is to preserve a surgical option should this approach fail and to remain as minimal invasive as possible.
Cost effectiveness of this technique remains to be demonstrated when compared with traditional procedures, which only rely in suture fixation to repair the Achilles tendon. Bone anchor’s additional cost needs to be weighed against a shorter recovery period and lack of immobilization, which may reduce working days loss and return to sport in active people.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved
Achilles tendon rupture; minimal invasive surgery; early rehabilitation; sports medicine