Name: Achilles Tendon Rupture Surgical Treatment
Uploaded: 2017-06-21T00:00:00Z
Channel: Arthrex

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VPT1-00858-EN | A | Achilles Tendon Rupture Surgical Treatment

Mark Campbell

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Achilles Tendon Rupture Surgical Treatment

Achilles tendon ruptures are reasonably common injury, most commonly in that weekend warrior 30 to 40 year old male, but it can be seen in any part of the population. And I'm not going to talk about all the specifics of diagnosis and imaging, but let's talk about treatment. How are these treated? And the question is the two options. Do we treat them with or without an operation? If you look at the historical literature comparing operative versus non-operative treatment, there's been some differences between them that has been clearly established in the literature. The operative side has a lower rerupture rate, accelerated recovery, increased plantar flexion strength because it restores that resting tension. Now, the other side of it is you do have an incision. You do have potential healing problems. So this has been pretty much the argument in the past. Now, currently there has been articles that Articles that have come out, that question how much difference the outcome might be. And I will tell you, I'm very nervous about falling into some of these statements that say you can treat everybody non-operatively. It just doesn't make sense to me. And there are some inherent problems with these studies that I think you need to look at very closely. I will agree treating non-operatively the tendon will heal. This is a chronic rupture that's gone back and looked at as you see in that bracket that is healed tendon. So I don't think anyone will question. It will heal, but it heals with an increased musculotendinous length. If you liken it to that stretched out spring on the right hand side. And that is not ideal. Blick's curve that looks at resting length versus tension shows that anything you go too far in that resting length to the right side, you start losing your functional strength. We really want to try to keep it as close to that resting length as possible, and the only way to assure that we will get that length is through operative means. So what are the goals of the treatment? Well, we want to avoid complications. And I think that's been a big issue people have with operative treatment. Of course we want good functional outcome. So good functional outcome I think will be obtained via good surgical care. But avoiding complications is a little more difficult. Until now, the biggest complications are this. This is wound problems with this very large exposure in a area of very poor healing in many people. We would like to avoid that. More studies have come out now that are showing that percutaneous treatment can clearly lower these operative risks. This is a meta analysis that looked at multiple studies comparing the two treatment options and found, as we would expect, there was significant decrease in wound complications with the miss, but also a significantly higher patient satisfaction with the miss approach, which I think makes sense. So what are we avoiding? Well, we're avoiding this. It kind of makes sense if you look at that picture that clearly is going to have disruption of the vascular supply and potential for wound problems. Norm talked about this in his soft tissue injury. Same as here. We want to move these people. We want to get them going. We want to stress this soft tissue injury so it will heal more normally. I don't think we can stress these people unless we have good operative fixation. Early weight bearing also has been shown to be very beneficial. Again I want to weight bear these people early. In the past I have often had problems with that big incision, having problems with healing, and I was afraid to get them moving too fast because I needed that incision to heal. This is a percutaneous technique. Jim McWilliams published, and this is somewhat rudimentary, but it makes a lot of sense. The problem with this, and he found very good outcome with this is it's a very technically difficult procedure to do. He's doing little hooks and grabbing the suture. That's very difficult to do if you can get through with it. His score was excellent. He had almost no complications. These patients did very well. L so the question, it's hard to do, but if we could get a modified repair that limited that big incision and allowed us to move them quickly, that would be the ideal situation. And Todd talked a little bit about the PA system. This is a fantastic device that makes this surgery easy. He showed a 14 minute tourniquet time. I believe it Orthocarolina looked at using this and kind of like McWilliams data showed excellent scores, excellent patient satisfaction, and their average time to return to activity was four months, which is spectacular. And they found no difference in plantar flexion strength when compared to the contralateral side. Re ruptures, zero cervical nerve injuries zero wounds and zero. I mean these this is doing exactly what we want to do. We want to avoid the complications. Avoid that and go to that. I don't know if you can even see that incision on that one. It's very nice approach. And again going back to this how are we going to fix that. Opening that and putting stitches in there. It just isn't going to work. So what if we can keep that together and avoid that zone of zone of injury as much as possible, much like bridge plating does. And that's what the PA system has allowed us to do. At the same time restoring that resting tension. I'm not going to go through the whole technique there. It's it's on the website. But you make this small incision over the Achilles tear and the pars jig, which is so nice and easy to use. Slide it under the tendon and the muscle belly will stop it at the appropriate level. And if you can see on the top right it's all numbered. This is like color by numbers. It's extremely easy. You push the first needle through. I leave the needle in place that locks the whole system there, and then you just place the sutures one, two, three, four, etc. through the holes marked one, two, three, four, etc. it looks hard. It's not. I put this up to show you there's multiple of these sutures coming out when you're done. It looks complicated. It's not. They're all color coded. Everything's numbered. It is very simple. You pull this through and you look on the bottom right hand side. You have excellent proximal Locking fixation. Then you pull it under the skin with SutureLasso and using 4.75 swivel locks, you fix this to the calcaneus. So what have you done? You've bridged this injury given stable fixation to the zone of injury. And when you look at the end, this is when it's done. You can almost not see the incisions. The resting tension has been restored. I get these people moving right away. They weight bear immediately. I'm in therapy 3 to 5 days and advance to full activity at 12 weeks if tolerated. And these people do extremely well and I've seen no wound complications. So in conclusion, Achilles tendon rupture does provide some treatment challenges, but I think the percutaneous treatment is the way to go. And I think Arthrex has now made it so it's easy and reproducible to do so. Thank you very much.

Achilles Tendon Rupture Surgical Treatment

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