Advances in Achilles tendon repair
Achilles tendon pathologies include rupture and tendonitis. Achilles tendon rupture, a complete disruption of the tendon, is observed most commonly in patients aged 30-50 years who have had no previous injury or problem in the affected leg and are typically “weekend warriors” who are active intermittently.
Achilles tendon pathologies include rupture and tendonitis. Many experts now believe, however, that tendonitis is a misleading term that should no longer be used, because signs of true inflammation are almost never present on histologic examination. Instead, the following histopathologically determined nomenclature has evolved:
- Paratenonitis: Characterized by paratenon inflammation and thickening, as well as fibrin adhesions
- Tendinosis: Characterized by intrasubstance disarray and degeneration of the tendon
Signs and symptoms
Patients with an Achilles tendon rupture frequently present with complaints of a sudden snap in the lower calf associated with acute, severe pain. The patient reports feeling like he or she has been shot, kicked, or cut in the back of the leg, which may result in an inability to ambulate further. A patient with Achilles tendon rupture will be unable to stand on his or her toes on the affected side.
Tendinosis is often pain free. Typically, the only sign of the condition may be a palpable intratendinous nodule that accompanies the tendon as the ankle is placed through its range of motion (ROM).
Patients with paratenonitis typically present with warmth, swelling, and diffuse tenderness localized 2-6 cm proximal to the tendon’s insertion.
Loss of kager’s fat pad after rupture
MRI demonstrating chronic degenerative signs in Tendo achilles rupture
Conservative Management of Achilles Tendon Rupture
Nonoperative treatment for Achilles tendon rupture is usually indicated for patients who are elderly and/or inactive, as well as for those with systemic illnesses or poor skin integrity. Patients with diabetes, wound healing problems, vascular disease, neuropathies, or serious systemic comorbidities are encouraged to opt for nonoperative treatment because of the significant risks of operative treatment (eg, infection, wound breakdown, repair dehiscence, neurovascular injury, perioperative complications).
Surgical management of Achilles tendon injury/rupture
A good open surgical repair is has a favorable outcome to quick recovery. This is one of the best video I have come across demonstrating the achilles tendon repair.
Augmentation of repair becomes necessary in chronic ruptures and various techniques have been described.
Peroneus brevis augmentation
” Gastronemius turndown flap augmentation is one of the best autogenous reinforcement methods following tendoachilles repair”
“Some of the biological soft tissue reinforcement products life Restore™ ,GraftJacket®,Zimmer® or Permacol™, TissueMend®,CuffPatch™, Shelhigh No-React® Encuff Patch, OrthADAPT™, Bio-Blanket ® have been studied in Ligament repairs but have their own complications and current evidence do not recommend their use in Tendo achilles repair”
“Synthetic nonabsorbable Gore-Tex®, Lars ligament ®, Leeds–Keio® or Poly-tape® have not been studied in Tendo achilles repair Artelon® and Sportmesh™ are the latest in synthetic absorbable tendon reinforcement products which have shown promising results”
Surgical Treatment of Achilles Tendinosis and Paratenonitis
In paratenonitis, fibrotic adhesions and nodules are excised, freeing up the tendon. Longitudinal tenotomies may be performed to decompress the tendon. Satisfactory results have been obtained in 75-100% of cases.
In tendinosis, in addition to the above procedures, the degenerated portions of the tendon and any osteophytes are excised. Haglund’s deformity, if present, is removed. If the remaining tendon is too thin and weak, the plantaris or flexor hallucis longus tendon can be weaved through the Achilles tendon to provide more strength. The outcome is generally less favorable than it is in paratenonitis surgery.
Minimally invasive Achilles tendon repair
Historically, open techniques have been utilized for repair of the rupture but can be complicated by wound-healing issues and infection. This percutaneous and minimally invasive technique minimizes this concern. The PARS provides the opportunity for consistently reliable capture of the proximal and distal aspects of the Achilles tendon and utilizes color-coded FiberWire suture.
The anatomically contoured guide is nondisposable, while the suture and passing needles come packaged in one convenient kit. The system provides the option of transverse or locking sutures, or both. The locking option allows the surgeon to incorporate a locked FiberWire suture on both ends of the ruptured tendon.
The colored sutures offer a more organized approach to identifying and securing matched pairs. The healed tendon achieves a more natural contour, unlike the typical hypertrophic tendon resulting from open repair. This minimally invasive technique is ideal for the middle aged individual, where there may be a heightened concern for wound-healing issues.
Achilles Midsubstance SpeedBridge™
Achilles Midsubstance SpeedBridge™ Repair combines the minimal incision PARS technique with two SwiveLocks into the calcaneus for a knotless repair. This procedure eliminates the weakest part of an Achilles repair, the knots, by using interference fixation of the suture after reapproximating the tendon rupture. The PARS technique or a traditional repair can be used on the proximal stump and then the suture is passed percutaneously through the distal stump to the Achilles insertion site. By eliminating the knots, the repair can possibly be stronger than the traditional open repair while limiting wound issues with a small incision.
” Knotless repair technique and bone anchoring devices offer better strength to repair and minimize the complications of open surgical repair”
Post operative rehabilitation
The FXPro™ Walker is built around an ultra low-profile sole that provides the smoothest possible transition from heel to toe for normal ambulation without stressing the foot and ankle. Spatula stirrups conform to the calf to reduce chafing and the vented liner ensures that your patients stay cooler and dryer.
The Air Traveler™ walker features a circumferential air bladder that provides the ultimate compression and security for the wearer. The AirTraveler™ Stirrup Walker is an economical, pneumatic walker. In comparison with the FXPro™, the Air Traveler™ ensures more compression with the inclusion of the circumferential air bladders. The posterior channel system effectively restrics movement without adding pressure to the achilles tendon.