Anatomic Relationship of the Sural Nerve when Performing Achilles Tendon Repair using the Percutaneous Achilles Repair System, a Cadaveric Study

Category: Sports; Trauma Introduction/Purpose: Minimally-invasive techniques for Achilles tendon repair are gaining popularity by orthopedic surgeons due to the reports of similar re-rupture rates with open versus percutaneous techniques with less wound complications and quicker recovery with percutaneous methods. The goal of the study was to quantify the relationship of the sural nerve to the Percutaneous Achilles Repair System (PARS) during Achilles tendon repair and identify sural nerve violations utilizing this system. Methods: The PARS was placed into ten lower extremity cadaveric specimens after simulation of an Achilles tendon rupture. After placement of the PARS jig and passage of the needles, careful dissection was performed in order to identify whether the sural nerve was violated and the distance of the sural nerve in relation to the passed needles was recorded. Results: Of the 10 cadaveric specimens, none had violation of the sural nerve during percutaneous needle passage. Zero of the 50 (0%) needles directly punctured the substance of the sural nerve, however, one needle was found to have come into close proximity separating the sural nerve and small saphenous vein but when the suture was passed and the PARS jig removed, the nerve was found remain intact with no evidence of entrapment. Conclusion: This study demonstrated the potential risk for sural nerve injury when using the PARS for Achilles tendon repair.

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Anatomic relationship of the sural nerve when performing Achilles tendon repair using the percutaneous Achilles repair system, a cadaveric study

Foot and Ankle Surgery ◽

10.1016/j.fas.2020.05.011 ◽

2020 ◽

Author(s):

Roddy McGee ◽

Troy Watson ◽

Adam Eudy ◽

Candice Brady ◽

Cheryl Vanier ◽

...

Keyword(s):

Achilles Tendon ◽

Sural Nerve ◽

Tendon Repair ◽

Cadaveric Study ◽

Repair System ◽

System A ◽

Achilles Tendon Repair ◽

Relationship Of ◽

Percutaneous Achilles Repair ◽

Anatomic Relationship

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Supine Surgical Achilles Tendon Repair

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000345 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0003

Author(s):

Katherine Sage ◽

Gregory Guyton

Keyword(s):

Achilles Tendon ◽

Supine Position ◽

Complication Rate ◽

Sural Nerve ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Wound Complications ◽

Achilles Tendon Repair

Category: Ankle, Hindfoot, Trauma Introduction/Purpose: Open Achilles tendon repair is typically performed in the prone position for easy visibility of the tendon, but serious complications may be associated with general anesthesia in this position. Open Achilles tendon repair with supine position has been described and potentially avoids these issues, but it is not known whether this position is safe. We reviewed the complication rate of supine open Achilles tendon repair in a retrospective series of patients, looking specifically at wound healing, infection, re-rupture, and sural nerve injury. Methods: CPT codes for Achilles tendon rupture were used to search the records of one surgeon for the years 2010-2014. The charts were then reviewed. Patients were included if they had an Achilles tendon rupture that was surgically treated with primary repair in the supine position within 15 days of injury. Patients were excluded if further reconstruction or tendon transfer was performed. A paramedian incision was utilized 1 cm medial to the Achilles sheath. Results: A total of 37 patients met the inclusion criteria. Of these 37 patients, 31 were men and 6 were women. The average age was 40.0 years (range, 20 to 66 years). Average length of follow-up was 159 days (range 25 to 1589 days). The average BMI was 28 (range 24-36). There were no major complications, including no infections or wound complications. No reruptures and no sural nerve injuries were observed. Conclusion: In 37 patients with early follow-up, supine open Achilles tendon repair had a complication rate equivalent to reported historical data for the prone procedure.

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Clinical Outcomes and Ultrasonic Evaluation of Percutaneous Achilles Tendon Repair

10.21203/rs.3.rs-590571/v1 ◽

2021 ◽

Author(s):

Ben-Mao Liu ◽

Hung-Chou Chen ◽

Chen-Kun Liaw ◽

Chia-Hsien Chen ◽

Chih-Hwa Chen ◽

...

Keyword(s):

Achilles Tendon ◽

Clinical Outcomes ◽

Sural Nerve ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Wound Complications ◽

Ultrasonic Evaluation ◽

Achilles Tendon Repair ◽

The Mean

Abstract BackgroundAchilles tendon rupture remains one of the most common tendon injuries in adult population. At present, randomized studies have failed to demonstrate the optimal management of Achilles tendon rupture. Wound complications have been significantly minimized since the emergence of percutaneous repairs when compared to traditional open methods. However, some studies suggested a higher incidence of rerupture rates and iatrogenic sural nerve injuries. The goal of this study was to present the clinical outcomes and ultrasonic evaluation of percutaneous Achilles tendon repair.MethodsBetween August 2015 and May 2018, 36 patients with an acute Achilles tendon rupture, treated in percutaneous repair, were studied retrospectively. American Orthopedic Foot and Ankle Society (AOFAS) score and the 10-point visual analogue scale (VAS) for pain questionnaires were sent to assess the clinical and functional outcomes. Ultrasonic evaluation was recorded using Möller grading system as an objective measurement.ResultsThe 25 male and 11 female (mean age 47.03 years) were clinically followed-up for a minimum of 12 months (average 28.97 months). No wound complications or reruptures occurred. Four(11.1%) patients reported sural nerve hypoesthesia and one of them required additional treatment. The mean AOFAS and VAS score was 92.6 and 1.8 respectively at the 12th postoperative month. Ultrasonic evaluation was performed at the average follow-up of 18.3 months and the mean points were 1.8. All treated tendons were healthily recovered and all patients were able to return to previous work or activities.ConclusionPercutaneous Achilles tendon repair offers good clinical outcome and no apparent increased risk of reruptures. The risk of iatrogenic sural nerve injury, however, remains the most occurred complication. Ultrasound can be used to visualize and examine the repaired tendon, which demonstrated satisfying healing process.

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Evaluation of Anatomic Relationship between Sural Nerve and Instrumentation during Mini-open Achilles Tendon Repair: A Cadaveric Study

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00259 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0025

Author(s):

Kurt M. Krautmann ◽

Gary W. Stewart

Keyword(s):

Achilles Tendon ◽

Sural Nerve ◽

Surgical Repair ◽

Open Repair ◽

Adult Population ◽

Tendon Repair ◽

Wound Complications ◽

Lateral Edge ◽

Relationship Of ◽

Mini Open

Category: Sports Introduction/Purpose: The Achilles tendon is one of the most commonly ruptured tendons in the adult population, and there is still no consensus on optimal treatment. While surgical repair may result in a lower re-rupture rate and quicker functional return, it also comes with risk of wound complications and sural nerve injury. If surgical repair is chosen, the surgeon may choose a traditional open procedure, a mini-open technique, or a percutaneous approach. The main advantage of the mini open repair method is the reduced wound complications that comes with a much smaller incision, while still maintaining similar re-rupture rates. The purpose of this study was to determine the relationship of the sural nerve to the Arthrex PARS jig and repair sutures. Methods: Cadaveric dissection was performed on 10 unpaired above knee amputation specimens. After severing the Achilles tendon and inserting the jig for a mini open repair, the sural nerve was dissected out to determine the rate of nerve puncture by the passed sutures. The jig was then removed to determine if the nerve was bound by the passing sutures or wrapped during suture locking. Results: The sural nerve was punctured 9 times out of the total of 50 sutures passed for an 18% puncture rate. All 9 punctures occurred in 4 specimens (Image 1), with the remaining 6 cadavers sustaining no punctures. Of the 6 unpunctured cadavers, 5 had all sutures passing anterior to the sural nerve, but in close proximity. One cadaver had all sutures passing posterior to the sural nerve. In all cadavers, removal of the jig and locking of the sutures left the sural nerve free with the sutures well fixed within the Achilles tendon. The sural nerve was also found to be within 1 cm of the lateral edge of the mini-open transverse incision in all cadavers. Conclusion: The Arthrex PARS jig was successful in preventing binding of the sural nerve during mini-open Achilles repair, but the sutures are often passed directly through the nerve during the procedure. The sural nerve is also at risk at the lateral edge of the mini-open incision used to insert the jig, and must be carefully protected during dissection down to the tendon.

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Biomechanical Comparison of Panda Rope Bridge Technique and Other Minimally Invasive Achilles Tendon Repair Techniques In Vitro

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211008436 ◽

2021 ◽

Vol 9 (6) ◽

pp. 232596712110084

Author(s):

Ting Wang ◽

Yuan Mu ◽

Yulei Diao ◽

Wenke Liu ◽

Yahong Wu ◽

...

Keyword(s):

Minimally Invasive ◽

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Tendon Repair ◽

Biomechanical Properties ◽

Repair System ◽

Postoperative Rehabilitation ◽

Achilles Tendon Repair ◽

Repair Techniques

Background: Although nonoperative management of acute Achilles tendon rupture (ATR) is a reasonable option, surgical repair has attracted attention for young and active patients. More reliable Achilles tendon repair techniques are needed to enhance recovery after ATR in this population. Purpose/Hypothesis: To biomechanically analyze the panda rope bridge technique (PRBT) and compare it with other minimally invasive repair techniques over a simulated, progressive rehabilitation program. It was hypothesized that PRBT would result in better biomechanical properties and enhanced recovery after ATR. Study Design: Controlled laboratory study. Methods: An Achilles tendon rupture was created 4 cm from the distal tendon insertion site in 40 bovine lower extremities, and specimens were then randomly allocated to 5 Achilles tendon repair techniques: (1) Achillon, (2) modified Achillon, (3) Percutaneous Achilles Repair System (PARS), (4) modified PARS, and (5) PRBT. Each group was subjected to a cyclic loading protocol that was representative of progressive postoperative rehabilitation for ATR (250 cycles at 1 Hz for each loading stage: 20-100 N, 20-200 N, 20-300 N, and 20-400 N). Results: The PRBT technique demonstrated significantly less elongation (1.62 ± 0.25 mm) than the 4 other repair techniques after the first loading stage of 20 to 100 N ( P < .05). All specimens in the 4 other groups developed a large gap (elongation ≥5 mm) at the 20- to 200-N loading stage. When overall biomechanical performance was examined, the PRBT group exhibited higher strength (20-400 N) and more mean loading cycles (984 ± 10) compared with the 4 other groups ( P < .05). Conclusion: In this bovine model, PRBT biomechanically outperformed the other minimally invasive Achilles tendon repair techniques that were tested and could therefore meet the requirements of accelerated rehabilitation. Clinical Relevance: The reduced tendency for premature rerupture and the overall improved biomechanical properties of PRBT suggest that ATR patients treated with PRBT may more readily complete early and aggressive postoperative rehabilitation protocols. In addition, they may have a lower risk of early irreversible suture failure.

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Transverse versus longitudinal incision for minimally invasive Achilles tendon repair

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00161 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0016

Author(s):

Daniel Bohl ◽

Eric Barnard ◽

Kamran Movassaghi ◽

Kamran Hamid ◽

Adam Schiff

Keyword(s):

Minimally Invasive ◽

Achilles Tendon ◽

Suture Material ◽

Tendon Repair ◽

Wound Complications ◽

Transverse Incision ◽

Longitudinal Incision ◽

Achilles Tendon Repair ◽

Deep Suture ◽

No Tourniquet

Category: Sports Introduction/Purpose: The rate of wound complications following traditional open Achilles tendon repair is reported at 7-8%. In an effort to reduce the rate of wound complications, orthopaedic surgeons have adopted novel minimally invasive techniques. The purpose of this study is to characterize the rate of wound and other early complications following a minimally invasive Achilles tendon repair, to identify any factors associated with increased risk. Methods: The postoperative courses of 55 patients who underwent minimally invasive Achilles tendon repair by two surgeons at separate academic medical centers were retrospectively reviewed. Repair technique was similar in all cases, making use of the same commercially available suture-guidance jig, silicone-impregnated deep suture material, and locking stitch technique. However, 31 procedures used a longitudinal incision and a tourniquet (one surgeon’s preference), while 24 procedures used a transverse incision and no tourniquet (the second surgeon’s preference). Of the 24 procedures using transverse incisions, 2 had to be converted to L-shaped incisions to achieve better access to the tendon. The rates of early complications within 3 months after surgery were characterized and compared between patients with differing procedural characteristics. Results: Of the 55 patients included in the study, 2 (3.6%) developed wound complications. Both wound complications appeared to be reactions to the deep suture material (see Table 1 for details). There was no statistical difference in the rate of wound complications between patients in the longitudinal incision/tourniquet group and patients in the transverse incision/no tourniquet group (6.5% versus 0.0%; p=0.499). Three patients (5.5%) developed sural neuropraxia, which manifested as mild-to-moderate subjective numbness with sensation remaining intact to light touch. There were no cases of re-rupture. At 3-month follow-up, all 55 patients had intact Thompson tests and well-healed wounds. Conclusion: The rate of wound complications following minimally invasive Achilles repair is low at 3.6%. The present study could not demonstrate a difference in risk for wound complications between patients treated with a longitudinal incision and tourniquet and patients treated with a transverse incision and no tourniquet. The wound complications we observed were primarily attributable to inflammatory reactions to the silicone-impregnated deep suture material. Patients should be counseled that although risk for wound complications may be lower with minimally invasive techniques, such techniques do risk sural neuropraxia and deep suture reaction. Further prospective analysis is warranted.

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Minimally Invasive Achilles Tendon Repair Using the Achillon Repair System

Techniques in Foot & Ankle Surgery ◽

10.1097/01.btf.0000235234.20325.f7 ◽

2006 ◽

Vol 5 (3) ◽

pp. 171-174 ◽

Cited By ~ 4

Author(s):

Andrew J. Elliott ◽

John G. Kennedy ◽

Martin O'Malley

Keyword(s):

Minimally Invasive ◽

Achilles Tendon ◽

Tendon Repair ◽

Repair System ◽

Achilles Tendon Repair

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Arthroscopically-Asissted Achilles Tendon Repair; Long-Term Results

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967114s00222 ◽

2014 ◽

Vol 2 (11_suppl3) ◽

pp. 2325967114S0022

Author(s):

Akın Turgut ◽

Mert Zeynel Asfuroğlu

Keyword(s):

Achilles Tendon ◽

Range Of Motion ◽

Sural Nerve ◽

Plantar Flexion ◽

Tendon Repair ◽

Long Term Results ◽

Calf Circumference ◽

Achilles Tendon Repair ◽

Arthroscopically Assisted

Objectives: The ruptures of the Achilles tendon (AT) are relatively common. Since there is no consensus on the best method of the repair of the AT; the treatment is determined on the preference of the surgeon and the patient. The study evaluating the cadaveric and short term clinical results done by our clinic in 2002, has shown us that arthroscopically Achilles tendon repair can be good choise in achilles tendon ruptures. Methods: Fortyfour patients who underwent arthroscopically assisted achilles tendon repair during 1997-2011 in Osmangazi University Orthopaedics and Traumatology Department were retrospectively observed. The mean follow-up time was 69,7 months. One of patients had bilateral rupture. The diagnosis was based on loss of plantar flexion strength, palpation of the gap in the tendon, and a positive Thompson test. MRI and USG were used when needed. The ruptures were left-sided in nineteen patients and right-sided in twentysix. The cause of the rupture was recreational sports activity in thirtyeight, fall from height in four, missing a step in a staircase in two. Return the regular activity, ankle range of motion as compared with the opposite side, calf circumference, and ability to walk and stand tiptoe were recorded. All patients were operated on within 2-32 days after the rupture. Thirtysix operations were performed under spinal anesthesia and eight operations were performed under general anesthesia. Tourniquet was always used. Before starting the procedure, the rupture site and location of the gap are marked. Using the common videoarthroscopic instruments, a 70 degrees scope was inserted into the AT through the stab incision made previously, and the torn ends of the tendon were visualized with plantar flexion an extension of the ankle. After the visualization of the torn ends of the tendon and repair by the technique of Ma and Griffith care was focused to contact the ends of the tendon anatomically; then the sutures were knotted. A short leg circular cast with the ankle in slight plantar flexion was applied. American Orthopaedics Foot-Ankle Society (AOFAS) score was used to evaluate the long-term results.. Results: All patients had satisfactory results that no reruptures had occurred. No significant difference in range of motion of the ankle and calf circumference between the opposite sides was observed in any patient. All patients could walk and stand on tiptoe. AOFAS mean score was 94.5 (65-100). The interval from injury to return to regular work and activities was 8-10 weeks. All the patients were able to return back to their activity level before surgery. In three patients temporary sural hypoestesia, in one patient permanent sural hipoestesia and in one patient wound enfection appeared. No sensory deficit was detected in the temporary sural hypoestesia patients after postoperative second year controls. Medical care was supported to the patient with the wound enfection and the enfection was under control in the early stages. Conclusion: In summary; arthroscopically-assisted percutaneous repair of AT appears to overcome some certain problems of open, conservative and percutaneous techniques; but the neurovascular structure damage risk especially the sural nerve remains a potent problem. Accurate knowledge of the anatomy appears to be a solution. Novel percutaneous repairs have been promising to minimize the risk of sural nerve damage.

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Functional Outcomes and MRI Results Following Knotless Repair of Acute Achilles Tendon Ruptures

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00459 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0045

Author(s):

Brian D. Steginsky ◽

Mallory Suhling ◽

Eric Giza ◽

Christopher D. Kreulen ◽

B. Dale Sharpe ◽

...

Keyword(s):

Surgical Technique ◽

Achilles Tendon ◽

Functional Outcomes ◽

Tendon Repair ◽

Surgical Techniques ◽

Wound Complications ◽

Distal Stump ◽

Achilles Tendon Repair ◽

Tendon Ruptures

Category: Ankle; Sports Introduction/Purpose: The surgical techniques for primary repair of acute Achilles tendon ruptures have evolved from large open incisions to mini-open and percutaneous techniques. Studies have demonstrated that lesser invasive surgical techniques may reduce the risk of post-operative wound complications. Knotless surgical repair of acute Achilles tendon ruptures can be performed through a mini-incision, but still permits a robust re-approximation of the tendon stumps and decreases suture burden through distal anchor fixation in the calcaneus. However, stress shielding and subsequent tendinosis of the distal tendon stump is a theoretical concern with this surgical technique. We hypothesize that our surgical technique allows for a durable repair through a minimally invasive approach, permitting a safe and accelerated rehabilitation protocol, excellent functional outcomes, and absence of distal stump tendinosis. Methods: A multicenter retrospective chart review was performed to identify all patients that underwent primary Achilles tendon repair using a knotless surgical technique with a minimum of one-year follow-up from three orthopedic foot and ankle surgeons’ practices. Exclusion criteria included: age <18, chronic Achilles tendon ruptures (>4 weeks), insertional Achilles tendon ruptures, revision Achilles surgery, peripheral neuropathy, and systemic inflammatory disease. All patients were contacted by phone and asked to return to the office for an MRI, clinical examination, and completion of functional outcome questionnaires. The primary outcome measure was the validated Achilles Tendon Total Rupture Score (ATRS). Secondary outcomes included the Visual Analog Score (VAS), postoperative complications, ankle range of motion, calf circumference, and single-heel rise. MRI was used to assess tendon continuity and healing, tendinosis, muscle atrophy, and bone marrow edema/stress fracture associated with anchor fixation in the calcaneus. MRI interpretation was performed by a single, blinded musculoskeletal radiologist. Results: Forty-three patients were identified with acute Achilles tendon ruptures. There were 36 patients (36/43, 84%) who underwent knotless Achilles tendon repair and agreed to participate in the study. The average time to clinical follow-up was 23.5 months (SD±16.3). The mean postoperative ATRS was 84.6 (SD±19.7). There was no significant difference in calf circumference (p=0.22), dorsiflexion (p=0.07), and plantarflexion (p=0.11) between the unaffected and surgical extremity at latest follow-up. One patient (1/36, 2.8%) experienced a re-rupture. There were no wound complications or neuritis. MRI was obtained in 26 patients (26/36, 72.2%) at an average of 17.5 months (SD±10.1). There were no MRI findings of distal stump tendinosis or calcaneal stress fractures. Thirty-two patients (32/36, 88.8%) returned to the same athletic activities one-year after surgery. Conclusion: There is paucity in the literature on functional outcomes following knotless Achilles tendon repair. In this multicenter study, we found that validated functional outcome scores and return to activity were similar to historical controls, with a low rate of surgical complications. MRI obtained in twenty-six patients (72.2%) at 17.5 months demonstrated an intact tendon without distal tendon stump stress shielding or calcaneal stress fracture. The knotless Achilles tendon repair is a unique surgical technique, minimizing suture burden and postoperative complications, while offering excellent functional outcomes and return to activity at two-year follow-up. The excellent clinical outcomes are corroborated by MRI.

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