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Achilles Tendon Repair Using Nonabsorbable Suture Loop for Modified Giftbox Technique

Miller, Timothy L. MD*,†; Harwood, Jared L. MD; Harrison, Ryan K. MD; Nerone, Vincent S. DPM

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Techniques in Orthopaedics: March 2015 - Volume 30 - Issue 1 - p 33-38
doi: 10.1097/BTO.0000000000000050
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The Achilles tendon is the strongest and thickest tendon in the body, but also one of the most commonly injured. The gastrocnemius and soleus muscles converge to form the “triceps surae” or Achilles tendon. The tendon is approximately 15 cm long and runs from the mid-calf to its insertion into the calcaneus. Achilles tendon ruptures occur in males more frequently than females and most commonly in male individuals between the ages of 30 and 60 years. Once diagnosed, options for treatment include surgery or nonoperative methods, with numerous operative and nonoperative treatment protocols having been described. We will describe a modified giftbox technique for Achilles tendon repair using a nonabsorbable suture loop.


The most common etiology for injury to the Achilles tendon is forced plantarflexion or rapid eccentric dorsiflexion in a plantarflexed ankle. This scenario is commonly encountered while playing sports and may be accompanied by an audible and palpable “pop” at the tear site. Often, patients report a feeling of being kicked from behind when the injury takes place. The patient experiences difficulty walking and weakness of plantarflexion.


Previously described methods for open end-to-end tendon repair include the Bunnell, Kessler, Krackow, triple-bundle, and “giftbox” techniques. The triple-bundle technique in combination with #2 Ethibond suture has performed the best under direct comparison with a mean tensile strength of 453 N.1 One variation of the Krackow technique with sutures that pass peripherally around the tendon and then through the opposite stump has been termed the “giftbox” technique. The giftbox method has been shown to have a >2-fold increase in the suture pullout strength.2 This has been attributed to using multiple suture strands across the tear site and tying notes away from the repair. Several variations of this technique have been developed.

Our technique uses a nonabsorbable suture loop (Fiberloop; Arthrex, Naples, FL). A study has suggested that the nonlocking loop stitch construct is inferior to a traditional Krackow locking stitch in terms of elongation and suture pullout.3 In contrast to those results, White et al4 found no difference in elongation between the 2 options and single load to failure was significantly higher for the suture loop technique. These studies, however, have not been performed in human tissue and not with the same suture configuration as the technique used by the authors of the current article.

Benefits of the suture loop technique include less passes through the native tendon, a greater number of suture strands across the tear site, shorter procedure times, and better grip on poor quality tendon tissue. In addition, the injury site remains free of knots, which is thought to increase surface area for tendon healing and eliminate a potential area of increased stress in the tendon-suture construct. All of these factors are intended to increase the rate of healing of the previously injured tendon.5 In addition, the suture loop technique creates a “suture tunnel” in the tendon stumps. This prevents damage to the suture during shuttling for the giftbox technique.


Although proponents of both surgical and nonsurgical intervention exist, it is generally held that in young, athletic patients, surgical repair produces lower rerupture rates and a faster recovery timeline.


After induction of anesthesia, the patient is intubated by the anesthesia staff. Regional nerve block to the lower extremity may be utilized per surgeon preference. Intravenous antibiotics are administered to begin the procedure. The patient is placed in the prone position with all bony prominences well padded for the entirety of the procedure. A pneumatic tourniquet is placed around the thigh before placing the patient prone. An examination under anesthesia is performed with the patient prone and includes a Thompson test.6 This is performed by squeezing the patient’s calf musculature bilaterally and comparing the amount of ankle plantarflexion that occurs upon calf squeeze with that of the contralateral, uninjured extremity.6,7

The lower extremity is then prepped and draped in the usual sterile fashion with the opposite, noninjured ankle prepped out sterilely as well. This allows the surgeon to judge appropriate tension of the repair compared with the uninjured side. The injured lower extremity is exsanguinated with an Esmarch bandage, and the tourniquet is inflated.

An 8 to 10 cm longitudinal incision centered over the tear site is made at the posterior aspect of the ankle just medial to the Achilles tendon (Fig. 1). Careful dissection is made through the soft tissue to expose the paratenon which is then incised sharply to create full-thickness flaps (Fig. 2). The tendon is exposed and the damaged ends of the tendon stumps are debrided sharply back to stable and healthy-appearing tissue (Fig. 3). A nonabsorbable suture loop is then woven in a repeating fashion 5 times through the distal and proximal stumps of the tendon (Figs. 4A, 5). A sixth pass of the suture loop is made behind the position of the fifth pass on each stump in order to lock the suture. The tails of each of the 2 suture loops are then passed out through the ends of each stump (Figs. 4B, 6).

An 8 to 10 cm longitudinal incision is made over the posterior ankle centered over the tear site (incision enlarged for demonstration purposes).
Deep dissection is made to expose the paratenon. Full-thickness soft-tissue flaps are created to include the paratenon.
Damaged tendon is exposed and frayed tendon stump ends are debrided back to stable healthy tendon.
Suture loop is woven through the distal tendon stump (A) and out the tendon end (B).
Suture loop is woven through the proximal tendon stump.
Suture ends from the distal and proximal stumps are passed through the opposite tendon stump with a Keith needle.

A modified giftbox repair is then performed by using a free needle to shuttle the ends of each of the 2 sutures through the opposite stump (Fig. 7). The tails of those sutures then cross the medial and lateral portions of the tendon and are tied behind the sutures that had been previously woven through the opposite stump (Figs. 8, 9). Tension is set with the knee in 90 degrees of flexion and with the ankle set to the same degree of plantarflexion at which the uninjured ankle rests. Initially 1 suture is tied statically, and the opposite is tied with tension applied. This step is performed to prevent overtensioning of the repair.

A, Suture ends are passed through the opposite tendon stump. B, All 4 sutures are passed through the opposite stump.
Suture knots are sequentially tied proximal and distal to the woven suture in each tendon stump.
Knots are sequentially tied proximal and distal to the woven suture in each tendon stump.

At this point, the suture tails are then passed back across the sides of the repair site and tied under static tension (Fig. 10). The repair is then reinforced with 0 absorbable sutures in interrupted fashion around the tear site taking caution to prevent injury of the core suture strands.

Final suture configuration after repassage and tying of medial and lateral suture tails.

The tourniquet is let down before closure and all notable bleeding vessels are cauterized. The wound is thoroughly irrigated, and the paratenon is closed in a watertight interrupted fashion with 0 absorbable suture. The subcutaneous tissues are closed with 2-0 absorbable suture, and the skin is closed in a subcuticular fashion with 4-0 absorbable suture.

The wound is dressed with a sterile dressing, a pound of cotton dressing, and a posterior sugar-tong splint with the ankle resting in approximately 15 degrees of plantarflexion to relieve any stress on the tendinous repair. The patient remains non-weightbearing on the operative lower extremity for the first 3 postoperative weeks.


Historically, the postoperative period has involved 4 to 9 weeks of prolonged immobilization. Recently, an accelerated rehabilitation program that includes early mobilization has been advocated. Rerupture rates seem to be equivalent with a decreased amount of postoperative complications.8 Our rehabilitation protocol occurs in 6 phases: phase I from 0 to 3 weeks, phase II from 3 to 6 weeks, phase III from 6 to 10 weeks, phase IV from 10 to 14 weeks, phase V from 14 weeks to 6 months, and phase VI from 6 to 9 months. Our criteria, goals, immobilization/bracing, weightbearing status, and exercises are detailed in Table 1.

Rehabilitation Protocol


Potential complications, as with all procedures, include bleeding, infection, thromboembolic disease, damage to surrounding soft tissues and neurovascular structures, and wound healing complications. Potential complications specific to the modified giftbox technique using the suture loop include the following:

  • Tendon overtensioning.
  • Loss of tension due to loose sutures.
  • Injury to suture during suture passage through the opposite stump.
  • Decreased tendon vascularity due to suture strangulation.
  • Inability to reapproximate the paratenon due to large suture knots.
  • Inability to regain active and passive dorsiflexion postoperatively.

With caution and the appropriate knowledge, these risks can all be avoided.


The modified giftbox technique using a nonabsorbable suture loop provides a strong and reliable construct for Achilles tendon repair. Results to date in 20 patients have shown good to excellent results with regard to plantar flexion strength, rerupture, and return to previous level of activity. The technique requires further investigation with direct comparison with the gold standard Krackow and standard giftbox techniques with regard to strength, rerupture rate, suture pullout, return to athletic activity, and long-term patient satisfaction. Preliminary results, however, have been promising for its utility.


1. Sadoghi P, Rosso C, Valderrabano V, et al.. Initial Achilles tendon repair strength—synthesized biomechanical data from 196 cadaver repairs. Int Orthop. 2012;36:1947–1951.
2. Labib SA, Rolf R, Dacus R, et al.. The “Giftbox” repair of the Achilles tendon: a modification of the Krackow technique. Foot Ankle Int. 2009;30:410–414.
3. Deramo DM, White KL, Parks BG, et al.. Krackow locking stitch versus nonlocking premanufactured loop stitch for soft-tissue fixation: a biomechanical study. Arthroscopy. 2008;24:599–603.
4. White KL, Camire LM, Parks BG, et al.. Krackow locking stitch versus locking premanufactured loop stitch for soft-tissue fixation: a biomechanical study. Arthroscopy. 2010;26:1662–1666.
5. Turker M, Cetik O, Kilicoglu O, et al.. Over-the-top knot placement technique enhances tensile stability of tendon repairs. Foot Ankle Int. 2010;31:1006–1013.
6. Thompson TC. A test for rupture of the tendo achillis. Acta Orthop Scand. 1962;32:461–465.
7. Simmonds FA. The diagnosis of the ruptured Achilles tendon. Practitioner. 1957;179:56–58.
8. Talbot JC, Williams GT, Bismil Q, et al.. Results of accelerated postoperative rehabilitation using novel “suture frame” repair of Achilles tendon rupture. J Foot Ankle Surg. 2012;51:147–151.

Achilles tendon; suture loop; giftbox suture

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