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Minimally Invasive Techniques: Fewer Complications, Better Result Phinit Phisitkul, MD Disclaimer Arthrex: Consultant Smith & Nephew: Consultant Mortise Medical: Stock First Ray: Stock Achilles tendon repair Elegant surgical

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Minimally Invasive Techniques: Fewer Complications, Better Result

Phinit Phisitkul, MD

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Disclaimer

Arthrex: Consultant Smith & Nephew: Consultant Mortise Medical: Stock First Ray: Stock

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Achilles tendon repair

 Elegant surgical dissection ??

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 Wound

complications !!!!! (up to 34.1%)

Treatment of Acute Achilles Tendon Ruptures. A Meta-Analysis of Randomized, Controlled Trials. Riaz J.K. Khan et al. J Bone Joint Surg Am, 2005 Oct; 87 (10): 2202 -2210 .

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Surgical vs Nonsurgical

 60 patients, Functional rehab vs open

repair

 Superior “Peak torque” of 14% at 18

months (p= 0.022)

 Superior RAND 36 PF and Bodily

Pain



Iikka Lantto,* MD, Juuso Heikkinen,* MD, Tapio Flinkkila,* MD, PhD, Pasi Ohtonen,* MSc, Pertti Siira,y PT, Vesa Laine,y MSc, and Juhana Leppilahti,*z MD, PhD Oulu University Hospital, Oulu, Finland

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Minimal Invasive Repair

 Achillon  PARs  Ma/Griffith  Maffulli  Endoscopic  etc.

(Guillo et al 2013 Surgeon) Ozsoy et al, FAI 2013 Kupcha et al, AJO 2008

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 6 RCTs, 277 repairs  No difference: re-rupture, tissue adhesion,

sural nerve injury, deep infection, deep vein thrombosis

 MIS: reduced superficial wound infection, 3

times greater patient satisfaction

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 12 studies, 5 RCTs, 781 patients  Comparable: clinical and functional

utcomes

 MIS: less re-rupture rate, deep and

superficial infections, wound disorders, hospitalization time, return to work

 MIS: more neurological complications

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Sural Nerve !!

Risk of injury

Neutral 14.8%
Internal rotation 25.6%
External rotation 0%

(Aibinder FAI 2013)

0% Nerve injury

(Hsu FAI 2015)

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Endoscopic Achilles Tendon Repair

 Indication: Acute Achilles

tendon rupture within 2 weeks

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Percutaneous suturing of the ruptured Achilles tendon with endoscopic

control. Doral MN, Arch Orthop Trauma Surg. 2009 Aug;129(8):1093-101.



Repair of achilles tendon rupture under endoscopic control. Fortis AP

Arthroscopy. 2008 Jun;24(6):683-8.



Arthroscopically assisted percutaneous repair of fresh closed achilles tendon rupture by Kessler's suture. Tang KL, Am J Sports Med. 2007 Apr;35(4):589-96.

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Techniques (modified Ma & Griffith)

 Six stab incisions  No 2 fiberwire, 4

strands repair

 Arthroscopy for

identifying soft tissue plane and avoiding sural nerve.

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Results

 Halasi, KSSTA 2003: 67 patients, F/U 12-60 months,

mean plantarflexion strength 86%, good to excellent 89%, DVT 1, partial rerupture 1

 Doral MN, Arch Orthop Trauma Surg. 2009 62

patients, 2 transient sural hypoesthesia, 95% returned to sports, Mean post-op AOFAS ankle- hindfoot 94.6. No re-ruptures, deep venous thrombosis or wound problems

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Personal Experience

 32 patients between 2008-2015  Mean f/u 4 years  Average tourniquet time 40 mins  Significant improvement in VAS, SF-36, FAAM  Return to sports at 3.6 months  Tendon enlargement 9.4%, superficial infection 3%, Sural

neuritis 0% so far

Accepted: Arthroscopy 2017

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