Jigless Knotless Internal Brace Versus Other Minimal Invasive Achilles Tendon Repair Techniques in Biomechanical Testing Simulating the Progressive Rehabilitation Protocol.

The jigless knotless internal brace surgery (JKIB), an alternative method for minimal invasive surgery (MIS) repair of acute Achilles tendon rupture, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as previous clinical research demonstrates. However, no comparative study on the biomechanical performance between JKIB and other MIS techniques has been reported until now. In this study, 50 fresh porcine Achilles tendons were used to compare the JKIB with open surgery (two-stranded Krachow suture) with other MIS techniques, including Percutaneus Achilles Repair System (PARS), Speedbridge (SB), and Achillon Achilles Tendon Suture System (ACH), using a biomechanical testing with cyclic loading at 1 Hz. This test was used to simulate a progressive rehabilitation protocol where 20 to 100 N was applied in the first 250 cycles, followed by 20 to 190 N in the second 250 cycles, and then 20 to 369 N in the third 250 cycles. The cyclic displacement after 10, 100 and 250 cycles were recorded. The survived cycles were defined as a sudden drop in measured load. In survived cycles, the JKIB group (552.3 ± 72.8) had significantly higher cycles than the open, PARS, and ACH groups (204.3 ± 33.3, 395.9 ± 96.0, and 397.1 ± 80.9, respectively, p < .01) as analyzed by post hoc analysis, but no significant difference as compared with the SB group (641.6 ± 48.7). In cyclic displacement after 250 cyclic loadings, the JKIB group (11.29 ± 1.29) showed no significant difference as compared with PARS, SB, and ACH groups (12.21 ± 1.18, 9.80 ± 0.80, and 11.57 ± 1.10 mm, respectively) and significant less displacement than the open group (14.50 ± 1.85, p < .01). These findings suggest that JKIB could be an option for acute Achilles tendon repair in the MIS fashion due to no larger cyclic elongation compared with other MIS techniques.

Achillon versus open surgery in acute Achilles tendon repair.

BACKGROUND: Open Achilles tendon repairs (OATR) are associated with high complication rates. Minimally invasive surgery (MIS) techniques like the Achillon Achilles tendon repair (AATR) were developed to reduce this. We performed a systematic review and meta-analysis to compare OATR with AATR. METHODS: We performed an extensive literature search including all studies that compared the two techniques. Outcomes assessed included overall complication rate, re-rupture rate, sural nerve injury, wound length, The American Orthopaedic Foot and Ankle Scores (AOFAS) scores and return to sports. RESULTS: Eight studies were suitable for inclusion totalling 210 patients in the AATR group vs 233 patients in the OATR group. Total complication rates were significantly reduced in the Achillon patients with odd ratio of 0.14 (CI 95%, 0.08-0.27, P<0.00001) in favour. There were no significant differences in re-rupture rate, sural nerve injury, return to sports and AOFAS scores following repair between the two groups. CONCLUSIONS: AATR has fewer overall complications compared with OATR. It should be considered as an alternative to open surgical repair.

Is Achillon repair safe and reliable in delayed presentation Achilles tendon rupture? A five-year follow-up.

BACKGROUND: To assess the outcome of delayed repair of ruptured Achilles tendon using the Achillon mini-open technique. METHODS: A review of all patients who underwent delayed repair (>10 days post injury) of ruptured Achilles tendon with mini invasive technique was compared to acute repairs carried out at the same unit. Leppilahti Score and Achilles Tendon Total Rupture Score (ATRS) were utilised. Complication rates including re-rupture were also reviewed. RESULTS: 14 patients were identified as having delayed repair (11-31 days). The mean follow-up period was 71 months (range: 58-92). There were no statistically significant difference in the Leppilahti Score and ATRS compared to patients treated acutely (<10 days post injury) in the same time period. 79% of patients with delayed repair reported good to excellent, comparable to 80% of patients having undergone acute repair. CONCLUSIONS: For those patients who would benefit from surgical repair, a mini-open technique using the Achillon suture-passing device remains a safe and reliable option for delayed presentation of 11-31 days.

An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device.

BACKGROUND: Percutaneous Achilles tendon repairs are gaining in popularity. This study aims to quantify the risk of sural nerve injury when using the Achillon device. METHODS: The Achillon device was instrumented into 15 cadaveric specimens and through dissection the rate of sural nerve puncture and the position of the sural nerve in relation to the Achilles tendon was documented. RESULTS: The sural nerve was found lateral to the Achilles tendon insertion point over a range of 14.3mm and crossed the lateral border of the Achilles tendon over a range of 57.7mm. The sural nerve was punctured a total of 6 times and in 4 out of 15 cadaveric specimens (27%). Four out of the 6 punctures occurred when the Achillon device was instrumented distally. CONCLUSIONS: The sural nerve displays a highly variable anatomical course and there is a risk of puncture during percutaneous Achilles tendon repair using the Achillon device.

The rate of sural nerve violation using the Achillon device: a cadaveric study.

BACKGROUND: Management of acute Achilles tendon rupture remains controversial. Open repair results in lower rerupture rates but is associated with complications from wound healing. Percutaneous and limited open repairs minimize soft tissue complications; however, there is a theoretical increased risk of sural nerve injury. We evaluated the risk of sural nerve violation with the Achillon limited open repair device in cadavers. METHODS: This cadaveric study consisted of 2 parts. The first part evaluated the frequency and location of sural nerve violation using the standard Achillon protocol in 18 intact embalmed left lower limbs. The second part involved device manipulation with 30 degrees of either internal or external rotation in 13 paired, intact embalmed lower limbs. RESULTS: In the first part, 5 of 18 specimens had at least 1 suture passing through the sural nerve. Eight of the 54 needle passes (14.8%) directly pierced the substance of the sural nerve. With internal rotation, 8 of 13 specimens had at least 1 violation of the nerve. Ten of the 39 needle passes (25.6%) directly pierced the substance of the sural nerve. With external rotation, no nerves were violated, significantly decreasing the risk of sural nerve violation versus neutral (P = .038) and internal rotation (P = .001). When sural nerve violation was evaluated in regard to instrument outlet, there was a higher risk in the proximal needle passer (outlet no. 3) compared with the distal needle passer (outlet no. 1) with both neutral testing and internal rotation (P = .027). CONCLUSION: This study demonstrated the potential risk for sural nerve injury using the Achillon device. CLINICAL RELEVANCE: External rotation of the Achillon decreased the rate of sural nerve violation. This may optimize its use in Achilles tendon repairs.

Achillon versus modified minimally invasive repair treatment in acute Achilles tendon rupture.

PURPOSE: To date, the best treatment of acute Achilles tendon rupture (AATR) is still inconclusive. Achillon seems to be a promising approach with satisfactory function and low complication rate. We hypothesize a modified minimally invasive repair (MMIR), which provides direct visualization of proximal tendon stump without specialized equipment that could provide comparable results. This trial is aimed to evaluate the functional and surgical outcomes of MMIR comparing with Achillon. METHODS: From February 2013 to February 2017, 114 patients with AATR were enrolled in this trial, underwent an alternative operation (Achillon or MMIR), and accelerated rehabilitation protocol. Forty-four patients took the Achillon and the other 70 patients took the MMIR at their subjective choice. One hundred eleven full follow-up data were obtained including Achilles tendon total rupture score (ATRS), time back to work, rerupture rate, overall complication rate, and operation time. RESULTS: There was no significant difference between groups in demographic characters. There was no statistical difference between both groups regarding to time return to work and ATRS at 3rd, 6th, 12th, and 24th month, respectively. Five reruptures and two Achilles tendons tethering to skins were found in the Achillon group, and two reruptures and one sural nerve injury in the MMIR group. No wound infection and dehiscence occurred. Overall complication rate in the Achillon group is higher (16.3% vs. 4.4%, p = 0.044). The operation time of Achillon is less than MMIR (34.84 vs. 39.71, p < 0.001). CONCLUSION: Both techniques combining with accelerated rehabilitation showed to be reliable and effective. MMIR is safer and more economical, and Achillon is faster.

Outcome following use of the Achillon jig for the repair of acutely ruptured Achilles tendons.

We report a series of 143 patients who underwent limited open Achilles tendon repair using the Achillon device at a mean follow-up of 25 months. All patients attending our institution with a diagnosis of acute Achilles tendon rupture were considered for operative repair using the Achillon jig unless they declined surgery or met the exclusion criteria. Following surgery patients were contacted and asked to complete an Achilles Tendon Rupture Score (ATRS). The clinical records were reviewed for evidence of complications, demographic information and evidence of re-rupture. Statistical analysis of subgroups including age at presentation, delay to surgery and patients with complications was carried out using the Kruskal Wallis non-parametric test. We report no re-ruptures at a mean of 25 months (minimum 12 months) following surgery. The mean ATRS score was 84/100 (range 15-100). There was no statistical significance between any of the subgroups analyzed. In conclusion, acute Achilles repair using the Achillon jig is safe, with a low re-rupture rate, excellent ATRS scores at a minimum of 12 months post-operatively and low complications. The incidence of sural nerve injury is much lower than published series of percutaneous Achilles tendon repair without the use of a jig.

Acute Achilles Rupture Percutaneous Repair: Approach, Materials, Techniques.

Closed traumatic Achilles tendon rupture is a common injury, especially in the aging athlete. Traditionally open repair has been recognized to offer a lower rerupture rate compared with nonoperative methods but with a higher complication rate. Percutaneous repair has been described to offer the benefits of open repair while avoiding the complications. The sural nerve is potentially susceptible to injury, and specialized instrumentation has been developed to avoid this event. This article discusses several techniques of minimally invasive Achilles tendon repair. Many authors have evaluated these techniques and the results are discussed here.

Subcutaneous Achilles tendon rupture: A comparison between open technique and mini-invasive tenorrhaphy with Achillon® suture system.

BACKGROUND: Surgical management of Achilles tendon rupture is still controversial: open techniques have a higher rate of soft tissue complications but a lower incidence of re-rupture than percutaneous tenorrhaphies. The aim of our retrospective study was to analyze and compare clinical and functional results in patients treated with either the conventional open or minimally invasive suture treatment with the Achillon® system. METHODS: A retrospective review of 140 patients was performed; 72 were treated with open tenorrhaphy, 68 with the minimally invasive Achillon® suture system. RESULTS: With a comparable re-rupture rate, there was a statistically significant reduction in surgical time, incidence of minor complications, time required to return to sport activities and return to work in the minimally invasive group. CONCLUSIONS: Achillon® mini-invasive suture system is a reliable tool for the Achilles tendon ruptures, able to reduce the incidence of soft tissues complications if compared to the classic open tenorrhaphy, while maintaining strength of the suture and leading to superimposed functional outcomes.

Evaluation of absorbable and nonabsorbable sutures for repair of achilles tendon rupture with a suture-guiding device.

BACKGROUND: The purpose of this study was to compare the functional and clinical results of Achilles tendon repairs with an Achilles tendon suture-guiding device using nonabsorbable versus absorbable sutures. We hypothesized that the absorbable suture would have clinical results comparable to those of the nonabsorbable suture for Achilles tendon repair with an Achilles tendon suture-guiding system. METHODS: From January 2010 to September 2013, 48 consecutive patients who had sustained a spontaneous rupture of the Achilles tendon underwent operative repair with an Achilles tendon suture-guiding device using 2 different suture types. All ruptures were acute. The patients were divided equally into 2 groups according to suture type. In the nonabsorbable suture group, No. 2 braided nonabsorbable polyethylene terephthalate sutures were used, and in the absorbable suture group, braided absorbable polyglactin sutures were used. The average age of the patients was 38 years (range, 28-50 years). Functional outcome scores and complications were evaluated. RESULTS: All patients had an intact Achilles repair after surgery. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot clinical outcome scores were 98 (range, 90-100) in the nonabsorbable suture group and 96.8 (range, 87-100) in the absorbable suture group. All patients returned to their previous work. The absorbable suture group had fewer postoperative complications (0%) than the nonabsorbable suture group (12.5%) (P < .05). CONCLUSION: Use of an absorbable suture in the treatment of Achilles tendon repair by an Achilles tendon suture-guiding system was associated with a lower incidence of suture reaction; however, functionally the results were not notably different from those using a traditional nonabsorbable suture. We conclude that repair with absorbable sutures is appropriate for Achilles tendon ruptures. LEVEL OF EVIDENCE: Level II, prospective comparative study.