Achilles tendon ruptures are common in the elite and recreational athlete and most often occur in the non-insertional region of the tendon complex. Arthrex has developed the Percutaneous Achilles Repair System (PARS). This allows less dissection, faster technique, less wound issues, and preservation of the blood supply to the peritenon. This technique utilizes #2 FiberWire.

Foot and Ankle

Procedure

Achilles Midsubstance SpeedBridge repair combines the minimal incision PARS technique with 2 SwiveLock® anchors 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 may provide additional strength than the traditional open repair while limiting wound issues with a small incision.
The newly launched PARS SutureTape provides the surgeon with 1.3 mm SutureTape suture which offers increased resistance to tissue pull-through, stronger knotted and knotless fixation, tighter and smaller knot stacks and better all-around handling characteristics.1
Reference
1. Arthrex Research and Development. LA1-00038-EN_B. 2017.

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Achilles PARS SutureTape With Achilles Midsubstance SpeedBridge™ Implant System

The PARS Achilles Midsubstance SpeedBridge™ implant system is a percutaneous, minimally invasive technique used to repair Achilles tendon ruptures. Using color-coded 1.3 mm SutureTape, the PARS system makes it easy to create a percutaneous locking stitch in the Achilles tendon, while staying inside the paratenon sheath.

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Achilles Midsubstance SpeedBridge™ Surgical Technique

When using the parse jig for the Achilles mid substance SpeedBridge technique, a percutaneous incision is made in a transverse manner just proximal to the palpable rupture. Alternatively, a small longitudinal incision can be utilized. The tendon is grasped and the jig is inserted with the inner arms inside the peritoneum of the Achilles tendon. The first parse needle is placed in the number one hole in the jig to stabilize the construct, while passing the other needles and sutures in sequential order. Lastly, the white SutureTape is then passed through hole number one. The jig can then be removed, which pulls the sutures out of the incision. Separate out each of the five sutures, the white, blue, and black suture tapes, as well as the two green and white FiberLink sutures. Each suture should be tested by pulling light tension through ten cycles to confirm appropriate hold in the tissue. On both sides, past the blue SutureTape under and around both green and white. Fiberlink SutureTak twice and back through the loop, then advance each loop back through the tendon using the free end of the green and white FiberLink sutures. This creates the locking stitch. Two stab incisions are made one centimeter below the superior aspect of the posterior calcaneal tuberosity. Medial and lateral to the Achilles tendon. Within these two stab incisions, insert the guidewire utilizing the drill guide with the white centering sleeve at 45 degrees from the centerline of the Achilles in the coronal plane, and 45 degrees from posterior to anterior in the sagittal plane. Guidewire placement can be checked under fluoroscopy. These two holes are drilled with a 2.6mm drill and tapped for later SwiveLock insertion. A banana. Suturelasso is passed through the distal stump of the Achilles and out of the rupture site. The SutureTape from the proximal portion of the tendon are then passed through the distal stump and out of the stab incisions distally. The suture tapes are then loaded through the eyelet of the Rd 3.9 biocomposite SwiveLock anchors. The foot is plantar flexed 10 to 15 degrees to approximate the tendon ends. The SwiveLock anchor is placed into the prepared hole to secure the suture tapes. The laser line feature on the SwiveLock shaft can be utilized to confirm when the anchor is flush, or two millimeters countersunk. The same steps are repeated for the suture tapes on the contralateral side. The incision is closed. Jumpstart antimicrobial dressing can be utilized and the result is a secure knotless repair of the Achilles tendon rupture.

Kirk McCullough, MD, (Leawood, KS) presents surgical pearls for using PARS (Percutaneous Achilles Repair System). The PARS features an anatomic contoured jig designed to fit within the paratenon. The PARS suture kit contains either color‐coded SutureTape or #2 FiberWire® sutures and PARS needles used to create strong percutaneous locking sutures on the distal and proximal ends of the Achilles tendon.

PARS (Percutaneous Achilles Repair System)

Professor Gordon Mackay, MD, (Glasgow, Scotland) describes multiple surgical cases for treating Achilles midsubstance ruptures using the Achilles Midsubstance SpeedBridge™ System and PARS Implant System. The Achilles Midsubstance SpeedBridge combines the strength of FiberWire® suture with SwiveLock® anchors for a strong knotless repair that anchors the Achilles tendon to the calcaneus.

Achilles Midsubstance Rupture Case Series

It's amazing that the Achilles tendon is the most or the strongest tendon in the body, probably the most important in terms of locomotion. Yet traditionally, our approach has been rather blinkered. We have had a tendency to tie the two ends together, often resulting in strangulation of the area that's injured. So with the mid substance SpeedBridge repair, which I'll explain, we like to refer to as a Hank procedure later. It has distinct advantages. It's a knotless system. It allows us strong fixation of the soft tissue directly to bone, and it can be carried out percutaneously with assist of the pars itself. It bridges the defect, basically providing support to prevent attenuation and lengthening, because even those that regard a successful outcome from conservative treatment are often left with weakness and difficulty with stairs and an inability to run. And this is because of lengthening, no matter how tight the Achilles is made at the time of surgery. Lengthening during rehabilitation. So even when the situation is rather unusual and we've got cavus feet, all we really want to want to do is mimic the same canvas anatomy to restore normal function. As I'm demonstrating here, and the hope is that we can put a bounce back into your step. And it's a simple procedure to carry out, as this animation illustrates. So we have proximal locking fixation. It's shuttled down within the Parthenon. We mark the insertion points into the calcaneus itself, going perpendicular and converging ever so slightly into the calcaneus. We can then align and tap. We shuttle our sutures through. We minimize soft tissue damage or interference. We respect these soft tissues with the stem cells for healing will be based. We then cut flush so there's no subcutaneous irritation. And close. And our early results have been remarkably good. And we can share those with you. And these have been published. This is principally Jim McWilliams. Early results from New York. And his results have been fantastic, as has been my experience and those of other surgeons. It's easy. It cuts your operation time. It respects your soft tissues. It's not less. It's is stronger. It standardizes that musculotendinous length and most importantly, it facilitates early mobilization. And this is a theme. If we can mobilize early, the patient is comfortable and our repair is more robust. This is a clinical example of patients simply marked and prepared for surgery. We then have our surgical approach. As you can see here, I've extended it into an L shape just to give me more exposure to the Parthenon. But I'm respecting the soft tissues and handling this very gently. The benefits of a percutaneous repair are well established, and we know that we can minimize wound complications and scarring and encourage faster healing. In reality, when the the pars jig is used, we then cycle the soft tissues to take any creep out of the soft tissues before we fix it distally. And we also bypass this critical 3 to 4cm where we have disorganized collagen, and it has a chance to remodel under under load. As we can see from Tom Clanton's paper, that the first ten cycles are the most the most crucial to taking out that attenuation in terms of our proximal fixation, it is robust enough to allow you to do a ski jump and lean back on the soft tissue, but the tips for tensioning are psycho. First of all, secure and slight. Aquinas approximately a centimeter tighter than the unaffected side because there will be still a little bit of creep within the soft tissues itself. Ensure your anchors are flush and not slightly proud beneath the soft tissues, and warn the patients that they expect a little of heel irritation because you are drilling into strong bone and fixing the soft tissues directly. The simple lasso, as you saw earlier, passes easily. And then when we have a chance at the end to look at our mid substance repair, you can see that everything is nicely realigned. Aromatically. And it's not surprising that our patients are comfortable and can enter into early phase rehab. So how different is a rehabilitation protocol? It's quite profound. We can encourage weight bearing and active movement from the start because we have the confidence in in our repair. We can plan to flex against resistance, and even this protocol is relatively conservative, with the boot being removed at six weeks, or really, as soon as the patient is comfortable around the house and then eccentric and more powerful. Loading can follow that with a 12 week recovery timeline for most. This is an example of one of our first elite athletes, who I was concerned that with this degree of disruption that any chance of remodeling would be very limited. And I was truly amazed when we took such a simple approach, left that soft tissue, just tucked it back in and let it remodel itself, that it could remodel as profoundly as it does within a cast. And but the difference is the collagen is loaded, and this is reflected in our imaging later. So we can see there's no significant when we image there's no segmental atrophy, there's no significant stress shielding, which would have been a concern of surgeons in the past. And the Achilles tendon, when imaged, is remarkably normal even at an early phase, some 10 to 12 weeks after surgery. There's less scarring because of the early mobilization, and the Hank procedure can look extremely good evenly at an early stage. This is some ten weeks afterwards. You can see the MRI here has the degree of remodeling that you would normally expect or anticipate, some maybe 6 or 8 months after surgery. But how does that translate into function? Well, it's remarkable, and I think every surgeon that looks after the patient will be much more confident about managing them surgically. When you can show this kind of benefit in terms of form and function. You'd normally be coming out of your cast at this point. And as you can see, he has no cast wasting. He's got a spring back in his step. And it's not even a fatigue element here, as he's forced to work for at least a minute in these exercises. The mid substance repair is quick. It's knotless technique. It transforms the patient experience. Most importantly, it's comfortable. It allows early mobilization and restores excellent function. Thank you.

Achilles Midsubstance SpeedBridge™ Repair

Child (D)

FiberWire® suture can be used for open Achilles repair. As compared to standard polyester suture, FiberWire suture has superior strength that provides tighter loop security during knot tying and increased knot integrity, while reducing knot profile.1
 
Reference 
1. Arthrex, Inc. Data on file (APT-2799). Naples, FL; 2015.

The PARS system is designed for a minimally invasive surgical repair of an Achilles tendon rupture. It features an anatomic contoured jig designed to fit within the paratenon. The PARS kit contains collagen-coated 1.3 mm SutureTape with new differentiating colors and PARS needles that are used to create strong percutaneous locking sutures on the distal and proximal ends of the Achilles tendon.

PARS Achilles Jig System

When using the percutaneous Achilles repair system, a small 1.5 to 2 centimeter incision is made in a transverse manner just proximal to the palpable rupture. Alternatively, a small longitudinal incision can be utilized. The tendon is grasped and the jig is inserted with the inner arms inside the peritoneum of the Achilles tendon. The first pass needle is placed in the number one hole in the jig to stabilize the construct, while passing the other needles and sutures in sequential order. Lastly, the white SutureTape is then passed through hole number one. The jig can then be removed, which pulls the sutures out of the incision. Separate out each of the five sutures, the white, blue, and black suture tapes, as well as the two green and white FiberLink sutures. Each suture should be tested by pulling light tension through ten cycles to confirm appropriate hold in the tissue. On both sides. Pass the blue SutureTape under and around both green and white. Fiberlink sutures twice and back through the loop, then advance each loop back through the tendon using the free end of the green and white FiberLink sutures. This creates the locking stitch. The proximal suture tapes are moved away from the rupture site, and the jig is then inserted distally and the SutureTape passing steps are repeated. Once the jig is removed, three suture tapes remain on each side, both proximal and distal, ready for re approximation of the tendon to complete the repair. The foot is placed in maximal plantar flexion, and the black suture tapes are tied first on both sides. 3 to 4 surgeon's knots are recommended. Next, the blue locked suture tapes are tied, followed by the white suture tapes completing the repair. The incision is closed. Jumpstart antimicrobial dressing can be utilized and the result is a secure repair of the Achilles tendon rupture.

Robert B. Anderson, MD (Green Bay, WI), discusses a case presentation and surgical technique using the Percutaneous Achilles Repair System.

Percutaneous Achilles Repair System (PARS)

Hello, I'm Bob Anderson from green Bay, Wisconsin. I'd like to share with you my experiences with the midst ViewSense acute Achilles tendon rupture. This is an issue that I see often in my practice, whether it be a lead athlete, a weekend warrior, or just an active individual who sustains one of these types of injuries and how best to treat it. Certainly, the management of the Achilles tendon rupture, an acute basis, has gone through an evolution over the years, and my own experience for years and years. I was always opening these extensile approach multiple sutures and always running the risk of developing an infection or wound healing problems. Fortunately, we've been able to migrate to a mini open type technique where we utilize the pars device that I'll demonstrate here in a few minutes. So let me demonstrate this through a case presentation. This is a 26 year old linebacker. Professional football player who sustained an obvious non-contact Achilles tendon injury on the field. We took him into the locker room and you'll see there in the illustrations on the bottom left that he had an obvious defect at that classic location, six centimeters above the insertion to the calcaneus. So you can palpate feel the soft dimple there, the defect there representative of a midshipman's defect. He had a positive Thompson sign with him in a prone position. And then when we flex the knees to 90 degrees, he also was found to have a positive metal sign. And that's demonstrated there on the photo on the bottom right as well. A positive metal sign. That's where again, an Achilles that maintains a resting tension. The toe should point to the ceiling to some degree on a injured Achilles, on one that does have a complete disruption of the Achilles tendon, you'll see the foot is flatter, it's lost its resting tension. So again, a positive metal sign. And if you have a defect, you have a positive Thompson sign. You have a positive metal sign. You pretty much don't need an MRI. You know what's going on. They have a mid substance acute Achilles tendon rupture. So again the question now is well what do you do you do with this? How do you treat it? Do you treat it surgically? Non-surgically as some of our colleagues in Canada and Europe have been describing of the last several years. And if you do operate on it, how do you do it? Do you still use the open extensile approach with its risks and its complications? Or do you go to a mini open approach and do you feel comfortable? Do you feel secure during that mini open approach? Well, I certainly do. I have not done an open approach for an Achilles tendon rupture over the past ten years, thanks to the development of the pars technique, now with the ability to also use SutureTape with it. So this is an article here that talks about is what's better optima treatment for the Achilles tendon or not operative treatment. This was a systematic review published in 2015 by Erickson and his group. What they found that was that operative treatment definitely decreases rerupture rates, but with the potential increase of minor complications like wound healing problems and infection as compared to non-operative management. But surgery also has the benefit of allowing an earlier return to work or, in my world an early return to sport. This was another article that came out in 2016, the American Journal of Sports Medicine. A prospective, randomized trial comparing both surgical and non-surgical treatments for acute Achilles tendon ruptures. And they found that by doing surgery restore calf muscle strength earlier, you basically are restoring the tension to that Achilles tendon complex. So obviously a huge advantage over a non-operative management. You get that tension back, which is so important, particularly in our more active and athletic population. And surgery may also result in basically better physical functioning and lower bodily pain than non operative group had as well. So again, advantages to doing surgery over non-operative management, particularly for our more athletic and active population. So why do an open fashion. We have the ability to do it percutaneous or with a mini open technique. And this is where I've evolved to now is with all my Achilles tendon ruptures that I see on an acute basis that are mid substance. I do use a mini open or pars technique. We find that the mini open as compared to the extensile open is still strong enough to perform early functional rehab, but it also decreases the risks of wound healing problems and infection. And basically, we also found that with the mini open technique as compared to non-operative measures, you can again recreate and maintain the proper muscle tendon unit integrity. Basically, you're restoring the tension back to the Achilles tendon complex that's necessary to get the best long term result. Particularly we're talking about the active or athletic population. So we've actually studied this quite extensively in my previous practice in Charlotte. This was a large study we did looking at the mini open versus open repair in a large number of patients. In fact, this was the largest review in the world literature 101 pars as compared to 169 open repairs. And basically we found that there were 6% fewer complications in the mini open or the pars group, and basically no evidence of neuritis on a long term basis. No re-operation for a deep infection. We also found there was a better return to baseline function at an earlier date with the Pars patients as compared to the to the open. And again, you'll see that we actually had better function even in five months in the parse patient population. So again, this was a paper that showed that the mini open technique can be used very well in our general population as well as our athletic population. Now I'd like to demonstrate this parse technique. Again, this is a device that allows us to grab the ruptured stumps, both proximal and distal. And it allows us to restore the tension while reducing the risks that you'd find with a more extensive open approach. We also find that by doing this through a mini open approach, and you'll see here I like to use the transverse incision. It allows for quicker healing, which means a quicker, more accelerated rehabilitation period of time and overall better outcome. So again, it's got all the advantages of surgery where you're actually closing the gap, but you're doing so without the risks of infection or wound healing problems. So again you're getting the advantages of nonoperative care. But again the whole benefit long term is restoring the tension as you'll see there. So we do secure those sutures with a foot and maximum plantar flexion. I am now using the SutureTape exclusively with the pars technique. We find that the SutureTape actually has a lower profile. It's softer. There's less concern about not irritation, but also it has better pull through strength with these soft tissues. So again, we find a tremendous amount of advantages now utilizing the suture tape with our pars device to actually capture both ends of the rupture itself. This is that same individual. Here he is at five months post-op. So again with this technique we restored his tension. We've gotten him to an accelerated rehabilitation program. And again, his return to sport was much quicker than we had in years past with the open techniques previously described. This is my post doc recommendations. Again, you have to treat this as a general recommendation. Everybody should be treated individually and based really on what their compliance level is, because certainly you want to protect them while these soft tissues heal. I typically place my patients in a non-weight bearing splint in plantar flexion for flexion for the first two weeks at two weeks. Then I let them come out of the splint. They go into a boot with wedges that maintain plantar flexion, and they can start gentle active dorsiflexion and plantar flexion. But we don't want them to come anywhere near neutral as far as the ankle position is concerned. We want to keep them in that more plantar flex position. As they start their gentle, active range of motion, we'll typically let them start to partial weight. Bear in the boot. With the wedges in place by 3 or 4 weeks, they'll progress to full weight bearing as the wedges are removed on a weekly basis, typically their full weight bearing in the boot by six weeks, and we'll continue that down to eight weeks until the final wedge is removed. During this time, we also want to begin to do some plantar flexion against resistance again holding off on any dorsiflexion. We'll then at eight weeks put them into a shoe that has a heel lift. And again, I think the most important thing is to have them avoid any passive dorsiflexion past neutral until 12 weeks. After that, they can progress as their symptoms and strength allow.

Robert B. Anderson, MD (Green Bay, WI), presents surgical tips and techniques for using the percutaneous Achilles repair system (PARS). The PARS features an anatomic contoured jig designed to fit within the paratenon. The PARS suture kit contains either color-coded SutureTape or #2 FiberWire® sutures and PARS needles used to create strong locking suture fixation on the distal and proximal ends of the Achilles tendon.

Using the PARS System Tips and Tricks

So for the purpose of this demonstration, I've already created a complete rupture of the Achilles tendon at this classic location, approximately six centimeters above the insertion of the calcaneus. We first addressed the proximal side. And so we're going to go ahead and use our pars on the proximal side. Place our sutures and then address the distal side. So again I've got my transverse incision I protect my nerve and then I protect the pseudo sheath as well. Now as I mentioned the pseudo sheath oftentimes is ruptured. But I'll have my assistant go ahead and just take a send and hold that pseudo sheath up so that I can then go ahead and take my pars and know that I'm inside the pseudo sheath. That's very important. You want the pars, these inner these inner tines of the device to be inside the pseudo sheath. That ensures that when you pull your sutures back out of this transverse incision, that those sutures will indeed be inside the pseudo sheath, thereby protecting your nerve from any iatrogenic injury. So what we've got now here is the device. We slide it through with the tines closed, and then we capture both sides of the Achilles tendon. Now you'll see as I do this, oftentimes the Achilles tendon will be pushed approximately. So the trick here is, is to go and take an Allis clamp. Now oftentimes people say, well, I put my sutures in and they slid out. I didn't capture any tendon. What usually has happened is that your device is too deep. It's too deep to the Achilles itself. You want to stay superficial. So with our device in and now we're captured the tendon itself, we're going to place our needles. The set that you have will come with three needles. You're certainly welcome to use all three at one time. My preference is use two needles. I think regardless, it's important to stabilize the unit, the pars unit to the tendon itself. So we'll go in position number one right here. And we slide through. These needles were developed. So they're not so sharp as to cut through a nerve. But they're sharp enough to get through the soft tissue and the integrity of the Achilles tendon itself. So now my first needle is there and it and it stabilizes the device. Now, what I'll do is I'll go in and put my second one. And these first two are going to be your transverse needles. So now you can see I've got my first two needles in place and they stabilize the device. Now you can certainly put a third needle here. But instead what I'm going to do is I'm going to set my needles down. So I'll take the white SutureTape. And again, this is a good time to go ahead and mention that while we use FiberWire very successfully for many years over the past year, I've gone to using a SutureTape exclusively. I like the SutureTape because it gives me a much smaller, softer, less prominent knot, so I have less concern for knot irritation. The other advantage of SutureTape it has better pull through strength for the soft tissues like the Achilles tendon. So we'll go ahead and we'll put the white one. That's our first one. We'll put that in the number one needle and I'll just draw that through. Now once I have that number one in I then will stairstep this down. So this now this needle then goes to number three. So now I pass number three. And then I'll take the blue stripe. Suturetape through the second needle. And again with that idea of stair stepping down I'll go ahead and draw this through. Leave about 50% on each side. And then again I'll go ahead. And now put this in number four. And number three and number four are utilized for our lock suture technique. If you didn't want to lock on either side of the stump you could just go position one, two and five. But in this situation and routinely I always use at least one lock suture on both sides of the rupture itself. So in this situation we're demonstrating this in holes three and four. So this is our first loop suture that will be utilized for our lock technique. And so I pulled that needle through and I'm going to go ahead and then put this in number five. And we're going to put the other loop suture. And you'll see what we did is we took the non Non-loop end and pulled that through for position number three. On this side we put a looped end for position number four. So again you got to make sure you got a loop on either side of the calf to appropriately lock that fifth suture. So now our fifth suture. This is what we call our zebra suture. It's a black white stripe. Again it's a SutureTape suture material. And we're going to draw that through. And then now we have our apparatus. You'll see on the device there's also a position six and seven. I'll turn that. So you can see that right there. Position six and seven. That's if you want to double lock on this side of the rupture. I do double lock. All my elite athletes are going to start earlier. Rehab perhaps more aggressive rehab to basically get more security for my sutures. I don't think you have to do it in all patients, but I like to do it in my elite athletes who are going to be a little more vigorous with their rehab program. If I do use position six and seven. I typically would have two FiberLink looped sutures that I place in both those holes to then utilize number five as a lock suture, as demonstrated here by just having one lock suture. We're going to actually have our blue striped suture become our lock suture. So at this point in time now with our SutureTape and our loop suture in proper position, I'm going to draw this out and you'll see that I can then go ahead and take these out. I know where I am. Take this. It's all about suture management. You want to make sure that you keep all your sutures in proper order and on the proper side of the Achilles rupture, and we'll do the same thing for the other side. But by having one free now and again, because suture management is so important here, I keep everything in the jig until I've had it all released, and then I separate them off to the side. So now what you have to do is you have to recreate the order that you put them in. So we'll have our white on top and black at the bottom. Now, as I mentioned before, our blue stripe is stripe is going to become our lock suture. So what you can do and there's many different ways to do this, but I go under the other three below it. Find my loop. Put that zebra through the loop of one of your loop sutures, and then your assistant can do the same on the other side. Now, as you see, then I can take the other loop. This is the non looped end of that other loop suture. I can use that to draw the blue stripe through from one side to the other. And then we'll do the same on the other side. And again that way I know I've kept my sutures in proper order. And then I test them all. So here's my most proximal one I test it my most distal one test it. And here's my locking suture I'm testing it. In this situation though, we've got excellent capture of this side. I'll take these sutures. I'll put them up on one end. Now, we just do this exactly the same thing on the other side. So now you can see we've got all of our sutures placed. Our blue is our locking. Our white and our black are our straight transverse non lock sutures. It is important to test all of them. So I'll go ahead and I'll test them I'll secure them. Now at this point our sutures are in place. They're secure. We're ready to go ahead and to secure them. What I'll typically do is then maximally plantar flex the foot. So again I'm a maximum plantar flexion guy. I don't believe in necessarily trying to duplicate any kind of resting tension or compare it to the contralateral side. I've never seen an Achilles tendon repair overtighten. So for that reason, I want to go in and secure these sutures in maximum tension. I'll typically secure my non lock sutures first, and then my last suture that I'll tie will be the lock suture. So in this situation we know our lock suture is the blue white stripe. So let's go ahead and we'll take the white. And we'll take the white first. And we'll tie that one down. So what I'll do is I'll go ahead. And you want to form a knot stack on one side. And again you're just laying a knot down because again there's no tension on the other side. And so I'm doing that again. It's nice and soft. So now on this side I'm going to be pulling against the knot that I just created and tensioning maximally. So you can see their plantar flexion and then laying that down. So once I have those in place I'll go ahead and I'll cut them off. So I want to get them out of the way. Makes it easier just to hem out of the way. And I'll do that just above the knot itself. Now I'll go to my other non lock suture which is the zebra the black white stripe. And we'll go ahead and secure that. But once it's secure on that side then I've got a point of fixation to tension against. So we'll go ahead and Attention that side. And then once down, you just cut off the redundancy. And then our last suture to address is the lock suture. So I'll really make sure I cinch that down all the way. And same for the last side. I'll lift that pseudo sheath up over my repair. And then I'll just make certain those knots are folded down anteriorly. So once I've done that, I'll take a vicryl suture. I'll basically do a subdermal suture capture where I'll come in and actually grab the soft tissues above the repair itself. And that will draw soft tissues with my healthy pseudo sheath over the repair itself. And then follow that with nylon sutures.

Anish R. Kadakia, MD, (Chicago, IL) presents the repair of Achilles tendon rupture using PARS (Percutaneous Achilles Repair System). He discusses the latest literature on Achilles repair and describes two different case series. The PARS features an anatomic, contoured jig designed to fit within the paratenon. The PARS Suture Kit contains color‐coded #2 FiberWire® sutures and PARS needles which are used to create strong percutaneous locking sutures on the distal and proximal ends of the Achilles tendon.

PARS: Optimizing Function with Minimized Wound Complication

This patient is a 32 year old male who presented with an acute Achilles rupture two days prior to presentation to the office. Most significantly, there are type one diabetic, which obviously places him at a higher risk for wound complication. And he's very athletic, playing basketball, softball and weightlifting. And our goal is to return him to his pre-injury level of activity. On physical examination, you can see the increased resting dorsiflexion, a palpable GAP, and a positive Thompson test with inability to plan a flex. In this case, when all three exam findings are positive, no advanced imaging is required. However, plain X-rays are routinely performed to ensure that an avulsion rupture has not occurred. We know that there is superior power and work associated with surgical repair of an Achilles tendon rupture, and you can see three different methods here. The question is how to get to appropriate recovery without an infection, because an infection mitigates all the benefits of surgery, and in many cases, the patient will be worse off as opposed to getting non-operative treatment. We look at the options in this case for an operative intervention. The goal is to get the patient back to obtain correct length of the actin myosin overlap. That is the primary benefit of surgery. We try not to utilize a leg tourniquet. You may drape the contralateral leg if desired, and the goal is to maintain correct length. And that's where a suture repair comes into play versus nonoperative intervention. The Pars system has been evaluated biomechanically and was looked at with average lows to failure compared to an open Krakow repair. Very similar techniques to load to failure and very similar for work to failure. So there's no significant difference in the strength of the repair. This is a large study looking at operative versus non-operative management of Achilles tendon ruptures by Carlson and team. And they show that the rerupture rate for surgical versus non-surgical intervention was statistically similar, with an infection rate of 2.2% in the operative group, with no infections in the in the non-operative group and superior heel rise for work only. And the DVT rate, which was screened for every patient, was 34%. And critically, what this implies is that the surgery itself does not place the patient at a higher risk for a DVT. It is the unfortunately, the incident of getting the Achilles tendon rupture. Prospective study evaluating 144 patients out of Iowa looked at the Rerupture rate, which was slightly higher in the functional rehab group but not statistically higher. But the infection rate was 1.4% in the operative group, which is for the deep infection, which is obviously very concerning. The strength was superior with surgery, and the DVT rate was 1.4% for symptomatic DVT. The largest series looking at an open repair versus a pars repair for acute Achilles tendon ruptures, looked at the pre-injury level of activity. At five months with the pars, it was 98% were back to activity, where only 82% were back to activity with the open. When looking at complications, although they noted no statistically significant difference numerically, there clearly was a difference in the Ritis rate was 0% in the pars, while 3% in the open. And this is important because the pars the minimally invasive technique. But it's a sub non placement of the suture, which is critical in eliminating the incidence of neuritis and complications. The wound infection rate was not zero but significantly less in the pars group versus the open. Most importantly, there were no deep infections as opposed to 2% of deep infection in the open group. It works and it does seem to be equal or slightly improved relative to an open approach. The problem that really occurs is the patient that gets a deep infection rate, although it may be 2% overall for that particular patient, it's really a disaster. This is a case of a 57 year old male who had an open repair GraftNet was utilized, and unfortunately, the patient underwent a large wound infection with exposed tendon and exposed bone. This can happen with any open approach and it's something we're trying to avoid. We did an open debridement. There was cultures that were taken both proximally and distally, and unfortunately the entire segment was infected in this case. Then a large agreement was required with excision of all the infected tissue and excision of that distal calcaneus. This can be seen here down to healthy bone. Once it was appropriately washed out, a large reconstruction was performed with an FHL tendon transfer and an allograft that was fixed with the Arthrex and Bio-Tenodesis set. As you can see here, one for the FHL transfer and the allograft was taken slightly posterior and fixed and significant plantar flexion. A reversible flap was required to cover this large defect, and final appearance is here with a very large wound. Although we did have a successful salvage where we were able to cover the defect and get his get his activity back to near normal. The concept is that a pars would allow for the same functional outcome as an open repair, without any reported incidence of deep infection, and avoidance of this significant complication. You can see here. Patient is placed prone. This is the most appropriate exposure for this technique. A longitudinal or transverse incision can be made. My preference is a longitudinal incision in case I need to do an extensile exposure, or have any difficulty in the case, and the incision in my preference is made slightly medial to the center of the tendon. I do cheat the exposure slightly more proximal, as I'm able to plant or flex the foot to engage the distal half of the tendon within the wound. Incision is then made approximately one to 1.5cm in length. The tendon is identified and then incised. The pars jig is then placed after grasping the Achilles tendon with an Allis clamp, and the pars jig is then placed within the nonaccrual fascia, and once all the sutures are past, you can see here we're easily able to pull all of the suture out, and this allows for excellent fixation of the proximal stump. There is a locking mechanism that has been designed within the pars and is the only jig that allows you to lock the suture with the minimally invasive fashion. Distally. You can see here we have the Achilles tendon now grasped and the pars jig is placed. Sub curl to the KreuLock fascia and it's sometimes easier to have the jig slightly narrow as you enter the fascia, and then slightly increase the width of the jig as you enter the distal aspect. The needles are then placed and is my preference to place the number one needle first that locks the jig in place, and then now I can easily place the second through fifth needles without any difficulty whatsoever. Once this is complete, the pars jig can then be again taken back into the central aspect of the wound, pulling all the suture deep to the fascia. It's very important that you feel the needle pass through the tendon, so you do not have a missed throw of the suture. You can see now with tension on the distal aspect of the suture, I'm able to easily plant or flex the foot and place significant tension. And it's a very strong repair. The sutures are then tied together in sequential fashion, utilizing the lock suture. Ideally primarily first, followed by the subsequent two sutures. You can see here now final post-op appearance with a very small wound, minimal scarring and thickening of the tendon, which I do not think is commonly talked about. But you can see with the pars technique as demonstrated here, this person is able to do six months single limb heal rise no wound complication, which is ideal. But note how the Achilles tendon is relatively thin without that thickening and tendinosis that didn't occur with an open repair. So in summary, the pars offers the same functional outcome compared to an open repair with clear superiority in infection, scarring, and thickness of the tendon and nerve. Complications. Given the current controversy that occurs over the benefits of open operative repair of Achilles tendon versus non-operative. It's really imperative that the surgeon consider the pars for all patients who are candidates for surgical repair, as it appears to be the one technique that allows for minimal risk of wound complications while maximizing the function of the patient. Thank you very much.

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 Rupture

Achilles Midsubstance SpeedBridge™ Repair

PARS SutureTape Technique for Achilles Rupture