A simple suture-guiding device for minimally invasive Achilles tendon repair

Abstract

Background:

Our hypothesis is to utilize a simple suture-guiding device for minimally invasive repair of Achilles tendon without any extra cost with a minimal risk of rerupture. The purpose of this study is to investigate the results of our minimally invasive technique for Achilles tendon repair using a simple ovarian clamp for suture guiding.

Materials and Methods:

Twenty patients with acute Achilles tendon rupture were treated with minimally invasive repair by an expert orthopaedic surgeon. Instead of an Achillon device, an ovarian clamp was directed to the proximal and distal parts of the Achilles tendon. All data relating to daily activities, walking, climbing stairs, sports activity, American Orthopaedic Foot and Ankle Society (AOFAS) and Thermannscores were recorded. Sural nerve was evaluated with physical examination for paraesthesia, hyperaesthesia, lateralis cruris and foot pain in all patient controls.

Results:

The average AOFAS score was 97.06 (76–100). All patients had intact Achilles tendon at last control. No rerupture was observed. Average time taken to return to work was 30.8 days (28–60 days). After 6 months, all patients returned to their previous sports activities.

Conclusion:

For Achilles tendon ruptures, minimally invasive repair techniques have shown successful results with low complication rates. Besides their success, some suture-guiding devices bring extra costs for patients or health insurance. Minimally invasive techniques may be performed with devices without any extra cost. Our new suture-guiding device provides knot placement under paratenon like Achillon device to improve outcomes, provides early return to work and minimizes the complications. Finally, our suture-guiding device has no extra cost.

Introduction

Treatment of Achilles tendon ruptures still remains controversial. Non-operative treatment using cast or functional bracing or operative treatment like open, minimally invasive or percutaneous techniques is the only possible treatment option. ¹ There is still no agreement on the best treatment option. Treatment options are ranging from non-operative treatment to open surgical repair. Several studies have shown similar functional results with non-operative treatment and open surgical repair but higher rerupture rate with non-operative treatment. ^2,3 Besides their advantages, open techniques also have risks for infection, nerve injury and wound healing problems. ^2,4,5

Many surgeons favour a formal operative approach to secure the best possible repair with the least chance of rerupture. ⁶ Many surgical procedures have been described. Minimally invasive techniques were developed and became popular in recent years to reduce the disadvantages of open treatment with minimal rerupture risk. Original mini-open method combined with the percutaneous technique was described by Kakiuchi in 1995. ⁷ Mini-open method combined with percutaneous Achilles tendon repair provides accurate apposition of tendon ends, better cosmesis, lower risk of wound healing problems, decreased operation time and minimal risk of infection. ^4,5,8 Besides these advantages, sural nerve injury is still be a problem with minimally invasive techniques.

Recent studies reported good to excellent results with minimal invasive and percutaneous techniques compared to open repair. ^4,6,9,10 A number of modifications had been described utilizing more complex tools and suture-passing techniques in recent years to improve outcomes and decrease iatrogenic sural nerve injury risk. Three incision techniques and single incision technique with Achillon device have been defined to avoid sural nerve injuries. ^6,11

Achillon Achilles tendon repair system (Integra Lifesciences Corporation, Plainsboro, NJ, USA) is a suture-guiding system for minimally invasive Achilles tendon repair. It combines the benefits of open and percutaneous repair. This system provides a strength repair and minimizes the iatrogenic sural nerve injury, but it has an extra cost and increases the treatment costs for the patient or health insurance.

In recent literature, it is emphasized that the best treatment for Achilles tendon rupture is surgical repair. ^6,9 Our hypothesis is to utilize a new suture-guiding device for minimally invasive repair of Achilles tendon without any extra cost with minimal risk of rerupture. The purpose of this study is to investigate the results of our minimally invasive technique for Achilles tendon repair using a simple ovarian clamp for suture guiding.

Patients and methods

From August 2011 to August 2013, 20 patients (19 males and 1 female) with acute Achilles tendon rupture were treated with minimally invasive repair. All 20 patients were followed at least 1 year. In 75% of patients, the aetiology of rupture was sports activities, and none of them had a history of Achilles tendinopathy. All were closed ruptures. The average age of the patients was 42.05 years (19–68 years). The average follow-up time was 20.9 months (12–37 months). The mean period from injury to surgery was 1.9 days (1–4 days).

The diagnosis was made clinically and radiologically. In physical examination, all patients had a palpable gap and a positive Thompson test. For the confirmation of diagnosis, ultrasound was performed to all patients.

Age, sex, injured side and follow-up time were recorded. At last follow-up, American Orthopaedic Foot and Ankle Society (AOFAS) and Thermann scores were performed for all patients. Tiptoe standing and walking and jump test with knee flexion on each extremity were evaluated.

Operative technique

All patients were operated within 48 h after the referral. All were operated in a prone position with tourniquet under regional anaesthesia. A 2 cm skin incision was performed at the medial side of Achilles tendon at the level of palpable gap. Paratenon was incised and retracted with stay sutures. The ruptured ends of the tendon were identified. Instead of an Achillon device, an ovarian clamp (Figure 1) was directed to the proximal part of Achilles tendon (Figure 2); after holding the tendon, the distal part of the clamp was sensed under the skin and three sutures were performed from outside and taken out from incision with the clamp. The same procedure was performed for the distal part of the tendon (Figure 3). Finally, all sutures were under the paratenon at the level of incision (Figures 4 and 5). Then, the ankle was placed at plantar flexion position and the sutures were tightened under direct visual control. After the last control, paratenon and skin were closed carefully. The operation was completed with a long leg cast, with the position of ankle at 20° plantar flexion. The average operating time was 30 min (25–50 min).

Figure 1.

The ovarian clamps. Different sizes may be used for different cases.

Figure 2.

Suturation of proximal tendon end with the clamp. Sutures are passing from lateral skin, lateral hole of the ovarian clamp, Achilles tendon, medial hole of the ovarian clamp and medial skin, respectively.

Figure 3.

Suturation of distal tendon end with the clamp. Sutures are passing from lateral skin, lateral hole of the ovarian clamp, Achilles tendon, medial hole of the ovarian clamp and medial skin, respectively.

Figure 4.

Knoting of sutures. All knots are placed inside the paratenon. After suturation, paratenon is closed over sutures.

Figure 5.

End of repair.

Follow-up

A custom-made splint was applied to patients 1 day after the surgery instead of cast. Patients were clinically followed every 2 weeks for 2 months and every 2 months for the first year. At the first follow-up, the skin sutures were removed and partial weight bearing with tiptoe was started. After 4 weeks, partial weight bearing with heel was started with heel support under the splint. Controlled active ankle dorsiflexion was allowed after 2 weeks post-operatively. After 8 weeks, the splint was removed and full weight bearing was allowed to the patient. Active plantar flexion, inversion, eversion and proprioception exercises were advised to patients after splint removal. All patients were evaluated at 3, 6 and 12 months post-operatively and at last control. All sporting activities were allowed after 6 months post-operatively.

All data relating to daily activities, walking, climbing stairs and sports activity were recorded. Sural nerve was evaluated with physical examination for paraesthesia, hyperaesthesia, lateralis cruris and foot pain in all controls.

Results

The average AOFAS score was 97.06 (76–100); 70% of patients were found excellent in Thermann scores, 20% of patients were found good and 10% of patients were found moderate.

All patients had intact Achilles tendon at last control. No rerupture was observed. One patient (5%) had superficial infection and treated with oral antibiotherapy. One patient (5%) had a complaint from paraesthesia at sural nerve trace and the neuropathic symptoms resolved spontaneously in 6 months.

Average time to return to work was 30.8 days (28–60 days). After 6 months, all patients returned to their previous sports activities. Tiptoe walking and jumping tests were the same compared to the normal side of the patients at last control examination.

Discussion

Minimally invasive repair techniques are becoming increasingly popular for Achilles tendon ruptures. They have so many advantages in reducing the complications of Achilles tendon ruptures compared to open repair and also provide good results. Minimally invasive techniques allow reapproximation of tendon ends and preserve paratenon vascularization and their gliding function, ¹ but some percutaneous techniques have been criticized for the difficulty in visualizing the tendon ends at the exact position. ^6,12 We performed the Achillon technique with a simple ovarian clamp without using the Achillon device. We protected paratenon and managed to keep the sutures inside paratenon.

Bhattacharyya and Gerber reported decreased operating time and hospitalization, reduced consumption of analgesics, less healthcare costs and no post-operative morbidity with minimally invasive technique for Achilles tendon repair. ⁴ Our mean operation time was 30 min and mean discharge from hospital was 1.5 days. We performed our minimal invasive technique using a simple ovarian clamp as suture guide so that there was no extra device cost charged to patient or to health insurance.

There are several studies in the literature about minimally invasive Achilles tendon repairs using either Achillon device or other suture-guiding techniques. Assal et al. reported their outcomes of minimally invasive Achilles tendon repair with Achillon device and they found better AOFAS scores, no wound healing problems and sensory disturbances. They reported only 3.7% reruptures with their technique. ⁶ Calder and Saxby evaluated the results of their minimally invasive repairs using Achillon device and they reported good functional results: early rehabilitation, return to sports at 6 months and no sural nerve injury with this technique. ¹³ Valente et al. reported their functional results of minimally invasive repair with Achillon device and they found no complications like rerupture, infection, sural nerve lesion and wound healing problems. They also reported improved AOFAS scores with their patients. ¹⁴ Aktas and Kocaoglu compared clinical and functional results of open repair with Krackow sutures and minimally invasive repair with Achillon device. Clinical and functional outcomes were found to be the same, but minimally invasive group had less local tenderness, skin adhesion and tendon thickness. ¹⁵ Daghino et al. compared minimally invasive repair with Achillon device and open technique and reported that minimally invasive technique had less complications, reduced surgical time and similar functional outcomes compared to the open technique. ¹⁶ Huffard et al. and Ismail et al. in their biomechanical studies found that suture configuration technique with Achillon device was as stronger as conventional suturing technique. ^17,18 He et al. compared their percutaneous Achilles tendon repair technique with traditional open repair and reported less wound healing problems and higher tendon healing rates. They offered Kirschner wire leverage before suturing for effective recovery of tendon length. ¹⁹ Kocaoglu et al. evaluated absorbable and non-absorbable sutures for Achilles tendon repair with a suture-guiding device and they found similar functional results with both suture types but less suture reaction with absorbable sutures. ²⁰ Similar to the literature, our results showed that this technique provides patients an early return to work, improved AOFAS and Thermann scores, with minimal risk of complications.

Complications like wound healing problems, cruris muscle atrophy, sural nerve damage, rerupture risk and deep vein thrombosis (DVT) may cause late recovery after Achilles tendon repair. Minimally invasive techniques cause minimal wound healing problems and DVT but may cause higher sural nerve damage and rerupture risk. Khan et al. in their meta-analysis, reported 30.4% complication rate with the open technique, 15.3% with closed technique and 10.3% with the percutaneous technique. ⁵ In a 2014 systematic review, incidence of complications after repair with Achillon device found 8.3% and only prospective series was considered this incidence decreased to 6.5%. ²¹ Khan et al. also reported 4% wound complication with the open technique and 0% with the closed and percutaneous techniques, respectively. ⁵

Rerupture of the tendon is one of the important complications after minimally invasive repair. In a 2005 meta-analysis, rerupture rates were found to be 3.4% with the open technique and 12.6% and 2.1% with the closed and percutaneous techniques, respectively. ⁵ Assal et al. found 3.7% rerupture rate after minimally invasive repair with Achillon device. ⁶ Bartel et al. in their systematic review found 3.2% rerupture incidence and it is also a supportive finding with the previous study. ²¹ Ozsoy et al. reported no reruptures with their minimally invasive repair technique. ¹ Bhattacharyya and Gerber hypothesized that more knot means more weak point on repair site. ⁴

Sural nerve injury is a potential complication after minimally invasive techniques; up to 60% of nerve injury is seen after minimally invasive repair. ^{22 –24}

Bartel et al. reported only 1.2% overall sural nerve injury incidence in their systematic review of Achilles tendon repair with Achillon device. They explained this low incidence as sutures inside paratenon protect nerve from entrapment. ²¹ Valente et al and Feldbrin et al. reported no sural nerve damage after minimally invasive repair with Achillon device. ^14,25 Ozsoy et al. also reported no sural nerve damage in their study. ¹

DVT is also reported as a complication of Achilles tendon repair. In a retrospective case series, it was reported 0.43%. ²⁶ Nilsson-Helander et al. found 34% DVT rate with routine Doppler ultrasound screening. ² Ozsoy et al. in their case series found DVT in one patient out of 13. ¹ Routine prophylaxis with low-molecular-weight heparin still remains controversial. Long-lasting immobilization of the extremity may alter the risk so DVT prophylaxis may be used for this type of patients. Minimally invasive repair provides us to start rehabilitation earlier. Calder and Saxby in their prospective study reported high success with early active rehabilitation after minimally invasive repair of Achilles tendon. ³ We had no DVT detected in our case series, and we used DVT prophylaxis for all patients.

We had no reruptures and no DVT seen in our case series. One of our cases had superficial wound infection, which was treated with oral antibiotherapy. Also one of our patients suffered from sural nerve paraesthesia and it resolved spontaneously in 6 months. Our overall complication incidence was 1%, which is a very low rate compared to the literature.

Besides the advantages of minimally invasive Achilles tendon repair with Achillon device, it has a higher cost of the device itself. Minimally invasive repair with Achillon technique without Achillon device maybe performed. Ozsoy et al. reported good results with their modified Achillon technique without using the device. ¹ Our results show that minimally invasive Achillon repair technique using a simple ovarian clamp is a reliable modification.

The limitations of our study were the absence of a control group and a relatively small sample size. Besides good results of our study, prospective randomized trials may be planned. Also biomechanical comparison of the minimal invasive techniques and suture configurations may be beneficial for the evaluation of repair strength.

Conclusion

For Achilles tendon ruptures, minimally invasive repair techniques have successful results with low complication rates. Besides their success, some suture-guiding devices bring extra costs for patients or health insurance. Minimally invasive techniques may be performed with devices without any extra cost. Our new suture-guiding device provides knot placement under paratenon like Achillon device to improve outcomes, provides early return to work and minimizes the complications. Finally, our suture-guiding device has no extra cost.