Editor’s note: In this article from the FORTE organization, Mahmut Nedim Doral, MD, PhD, FORTE president Gazi Huri, MD, and colleagues present a surgical technique for endoscopic repair of Achilles tendon rupture. Look for more articles from FORTE members in future issues of Orthopaedics Today Europe.

Acute Achilles tendon rupture is one of the most common injuries of the foot and ankle. It has a substantial potential to cause significant morbidity with a 50% to 60% rate of return to pre-injury activity levels for elite athletes following injury. Despite several conservative and surgical treatment options available, there is still no consensus regarding the optimal management of the acutely ruptured Achilles tendon, and management is still determined by surgeon and patient preferences.

The management of Achilles tendon ruptures should be based on reducing morbidity, early return to full function and minimizing complications. Surgical treatment options, such as open repair and mini-open and percutaneous repair, have gained popularity over nonsurgical treatment during the last decade. Recently minimally invasive approaches to treat acute Achilles tendon ruptures have been described to help achieve better outcome and early return to sport.

A modified Bunnell suture configuration is used. Initially, the suture passes from the superomedial stab incision (No: 1). The suture is carried distally with zig-zag fashion. The final step for suturing is carrying the suture proximal and then out from the superomedial portal again.

In this article, we discuss a less-invasive surgical technique for Achilles tendon ruptures that has the advantage of low complication rates compared with open procedures.

The recommended time to perform endoscopic-assisted percutaneous Achilles tendon repair is 7 to 10 days after the injury and the distal part of the tendon should be long enough — more than 2 cm — to be able to firmly and reliably grasp the distal tendon. A history of previous Achilles tendon surgery, open rupture and presence of skin lesions around the surgical site are relative contraindications.

To obtain the best portal location, we perform the surgery with the patient positioned prone and the injured foot in about 15° plantar flexion. It is done without a tourniquet under infiltrative anesthesia since being able to fully communicate with the patient during surgery is crucial to ensure active ankle motion. The rupture site and location of the gap should be marked prior to the procedure.

To minimize local bleeding, the skin, subcutis and paratenon should be infiltrated with 20 mL to 50 mL 0.9% saline solution with local anesthetic of 1% Citanest 5 mL (prilocaine HCI, AstraZeneca) and 0.5% Marcain 5 mL (bupivacaine, AstraZeneca) around the eight planned stab incisions made proximal (about 5 cm) and distal (about 4 cm) to the tendon gap. Surgeons should be careful on the lateral side, particularly in the proximal area where the sural nerve is located and crosses the Achilles tendon. The stab incisions are enlarged via the nick-and-spread technique and are used for needle entry. The puncture site is then shifted approximately 0.5 cm to 1 cm toward the middle and the paratenon is examined with a 4.5-mm 30° arthroscope via the distal lateral incision with the injured foot positioned at about 15° plantar flexion (Figure 1).

The torn ends of the Achilles tendon should be visualized and manipulated within the paratenon if necessary. We prefer to use PDS No. 5 double loop (Ethicon Inc., Johnson & Johnson) suture with a modified Bunnell configuration to pass the suture through the Achilles tendon under endoscopic visualization. The sutures are tied so they end in the proximal lateral end with the ankle positioned at 90° neutral (Figure 1). This step should be repeated once or twice with attention paid to the 90° position on the ruptured side after the patient sets the foot to neutral 90° during suture fastening.

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During suture passage, the surgeon places the scope alternatively in the various entry portals and inspects the Achilles tendon from the medial and lateral aspects. He or she also inspects the proximal and distal stumps from the proximal and distal directions to ensure the tendon stumps are clearly juxtaposed. The sutures are placed in the tendon at different levels in the coronal plane to ensure the risk of cutting out is minimized during tensioning. Finally, the sutures are tensioned and tied in the proximal medial entry portal with the ankle in neutral position and the tendon approximation is checked with the scope.

After fastening the sutures, the patient should perform the required ankle motion while the knee is in 90° flexion. Before securing the sutures, a final endoscopic evaluation is performed (Figure 2). After dorsiflexion and plantar flexion are performed by the patient, “the “gap” seems to vanish.

The patient is seen undergoing final evaluation of the Achilles tendon repair at the procedure’s conclusion.

Intratendinous bracing is performed and evaluated for functionality. To enhance the healing response, platelet-rich plasma (PRP) is injected at the end of the operation. Infiltration of autologous growth factors via PRP appears to help improve the biological tissue healing response and has been shown to be safe and effective.

The skin incisions are then closed. Early active rehabilitation with walking as tolerated and weight-bearing without a brace, splint or special shoe is started on the first postoperative day, as is passive range of motion training.

The percutaneous repair technique, which was described to reduce the complication risks, presents difficulties for achieving proper contact of the tendon stumps and adequate initial fixation and may lead to tendon lengthening due to a lack of inadequate approximation of the tendon ends and having sural nerve entrapment risk. Minimally invasive percutaneous repairs do not provide direct visualization and the endoscopic percutaneous technique allows early active range of motion training and weight-bearing after a short period of cast immobilization.

Percutaneous Achilles tendon repair done under endoscopic control with local infiltrative anesthesia is a safe technique with good functional outcomes and minimal risk of complications compared with open surgery or other minimally invasive approaches. It may be more cost-effective than open techniques. Furthermore, the procedure protects the paratenon and therefore should enhance biologic healing. Preservation of the paratenon also decreases the gliding resistance of the extrasynovial tissue. Direct visualization and manipulation of the tendon ends provides a stable repair that allows early weight-bearing and can be used in athletes. Early functional postoperative rehabilitation may improve the outcome.

For more information:
Mahmut Nedim Doral, MD, PhD, Gazi Huri, MD, and Egemen Turhan, MD, can be reached at Hacettepe University, Department of Orthopaedics and Traumatology, 06100, Ankara, Turkey; Doral’s email: mndoral@gmail.com; Huri’s email: gazihuri@yahoo.com; Turhan’s email: dregementurhan@yahoo.com.
Gürhan Dönmez, MD, can be reached at Hacettepe University Department of Sports Medicine; 06100, Ankara, Turkey; email: gdonmez_1805@yahoo.com.
Defne Kaya, MD, can be reached at Biruni University, School of Physical Therapy, Istanbul, Turkey; email: defne@hacettepe.edu.tr.
Mustafa Sargon, MD, PhD, can be reached at Hacettepe University Department of Anatomy, 06100, Ankara, Turkey; email: mfsargon@hacettepe.edu.tr.

Disclosures: Dönmez, Doral, Huri, Kaya, Sargon and Turhan report no relevant financial disclosures.