What's In My Bag? Midsubstance Achilles SpeedBridge with James McWilliam, MD
Q. Why do you prefer the percutaneous approach to Achilles tendon repair?
A. Percutaneous Achilles repair enhances outcomes in two ways. Firstly, percutaneous repair is associated with a lower complication rate. Secondly, I firmly believe that, by less violation of the soft tissue envelope, a percutaneous repair leads to a better organized, stronger tendon and quicker healing.
Q. Is a percutaneous repair strong enough to allow for early weight-bearing and mobility?
A. Numerous bench studies have shown superiority of percutaneous repair when compared to Krackow technique in terms of strength-to-failure and tendon lengthening prior to failure. Our own clinical study demonstrated no failures of repair two years after percutaneous technique even with immediate weight-bearing and an accelerated rehabilitation program.*
Q. Describe the evolution of your approach to percutaneous Achilles tendon repair.
A. I was trained to do an open repair and was usually satisfied with the results. Occasionally, however, I would encounter wound complications and/or pain and disability due to tendon adhesions and chronic swelling. I began percutaneous repair using a modification of the Kakiuchi technique, retrieving the sutures in an intrasynovial fashion using a crochet hook. I immediately noticed an improvement in patient satisfaction with regards to pain and return to activity.
With the release of the Arthrex PARS system, locked sutures are possible, a feature that I feel enhances repair strength and prevents suture creep and subsequent tendon lengthening.
Lately, I have been using a knotless PARS technique, with traditional percutaneous suture passage proximally with anchoring of the sutures into the heel (through the distal Achilles stump) directly into the calcaneus. This technique further minimizes soft tissue dissection and enhances repair strength. In addition, local irritation from bulky suture knots isobviated.
Q. What are the benefits of the Arthrex PARS system?
A. Economical, ergonomic, anatomic and efficient:
- Economical: nondisposable jig, the only cost is for the sutures and needle
- Ergonomic: contoured handle facilitates jig placement
- Anatomic: wide paddles ensure tendon capture by sutures
- Efficient: colored sutures enhance suture management
Q. With the knotless technique, how do you ensure apposition of the tendon ends after repair?
A. Regardless of the position of the tendon ends, the tendon will heal. If the tendon ends are far apart, scar will bridge the intervening defect. The goal, therefore, is not tendon apposition, the goal is restoration of appropriate length of the musculotendinous unit. This is best effected by draping the uninjured extremity into the sterile field and reproducing appropriate resting tension.
When using the crochet hook method, I would mildly over-tighten the repair, assuming suture creep and subsequent lengthening. With the locked suture of the PARS or the Knotless-PARS repair, I try to avoid over-tightening as I feel that suture creep and late lengthening is unlikely.
Q. What is your post-op protocol following Knotless-PARS repair?
A. Immediately postoperatively, patients are placed in a short leg cast ingravity equinus. On post-op day 3 – 5 they are placed in a CAM Walker with a modular Achilles wedge. PT starts day 5 – 7 with progressive ROM, strengthening, and proprioceptive exercises. The CAM Walker is removed at week 8 and activity as tolerated is allowed at week 12.
Q. What do you see in the future of Achilles repairs?
A. The Midsubstance Achilles SpeedBridge is a big advancement in tendon repairs and is based upon the InternalBrace concept popularized by Gordon Mackay and Arthrex. By restoring appropriate soft tissue length/tension in a stable fashion, we can appropriately stress the repaired soft tissue (in this case, Achilles tendon). Early motion allows for avoidance of “cast disease” and results in a better organized tendon with improved strength and flexibility.
In the future, we will learn to harness the body’s own mechanisms to improve healing. Preliminary results in an animal suggest enhanced healing of Achilles repairs with application of bone marrow aspirate concentrate. As we become more efficient in concentrating and activating the patient’s native stem cells, the speed and quality of tendon healing will dramatically improve.
* Article Reference:
Patel VC, Lozano-Calderon S, McWilliam J. Immediate weightbearing after modified percutaneous Achilles tendon repair. Foot Ankle Int. 2012;33(12):1093 – 1097.