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Achilles avulsion- Reattachment using an Arthrex Biocomposite anchor

    Overview

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    Learn the Achilles avulsion: Reattachment using an Arthrex Biocomposite anchor surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Achilles avulsion: Reattachment using an Arthrex Biocomposite anchor surgical procedure.
    Achilles tendon ruptures are one of the most common sporting injuries encountered in the emergency department.
    Reported incidence varies, between 11 and 32 per 100,000 population. Whilst the majority of injuries involve the mid-substance, a small number are avulsion injuries, where the achilles fails at the tendon insertion, this can occasionally involve an avulsion fracture of the calcaneum.
    There is bimodal distribution of sleeve avulsions, the majority will occur in middle aged men during sporting activity. A series by Nunley in 2016 found that 10 of 11 patients were male, and all sustained the injury during sporting activity. approximately 60% were over weight or obese, other associations were diabetes and crystal arthropathy. The injury is also seen in the more elderly population often with co-morbidities.
    It is important to diagnose avulsion injuries prior to surgery, as traditional end to end fixation will not be possible due to the lack of significant distal achilles tendon volume. Clinically, a defect or pain and bogginess may be located over the posterior heel, more distally than one would expect for a mid-substance rupture.
    Achilles tendon avulsion is often a “sleeve” type injury where the tendon is avulsed along with a sleeve of periosteum, bone or both, the avulsion may not be complete, and often there are residual parts of the Achilles that remain attached to the calcaneum, usually medially and laterally.
    The location and nature of the injury makes it a different entity from a mid-substance rupture. In common with other sleeve injuries (for example the deltoid ligament or patella tendon), the quality of healing at the bone tendon interface can be inferior; restoring optimal tension in the achilles is less predictable, and bulkiness of scar tissue around the posterior calcaneum tends to be poorly tolerated.
    In Achilles avulsion injuries, the proximal tendon is prone to retraction, surgery is aimed at restoring appropriate tension in the tendon and allowing early functional rehabilitation.
    There are a number of methods of reattaching the Achilles tendon. Traditionally interosseous sutures were passed through drill holes in the calcaneum. Fixation can be limited by the volume of bone stock available, requires dissection medially and laterally, and the surgeon might be guided to their fixation points based on bony anatomy as opposed to optimal location for the tendon. Probably the most straight forward and efficient way is with the use of suture anchors, such as the Arthrex Bio-Corkscrew (slowly resorbable) anchors demonstrated in this technique. The suture anchors can be tied on top of the Achilles tendon, the sutures can be under-sewn into the tendon to avoid prominence of the suture knots. Alternatively knotless systems are available such as the Arthrex Speedbridge, which uses a broader suture tape that reduces the risk of the suture cutting out, rather than knot being tied onto the tendon. The repair is secured with two interference screws distally, which also produces a greater area of compression of the Achilles onto the posterior calcaneum
    Readers will also find of interest the following OrthOracle techniques:
    Achilles tendon repair-open technique.
    Achillon for Achilles repair
    Achilles Reconstruction :Flexor Hallucis Longus tendon transfer using Arthrex Biotenodesis screw

    Indications


    INDICATIONS
    Reattachment of the Achilles tendon should be considered in cases of confirmed avulsion of the Achilles tendon. Confirmation of an avulsion should be made both on clinical and radiographic grounds.
    In active individuals, reattachment of the Achilles tendon can restore length and therefore function of the gastrocnemius-soleus complex.
    As ruptures of the Achilles insertion are often sleeve injuries, and may on occasion, involve partial avulsion of the calcaneum, they heal differently from mid-substance ruptures, and rely on tendon to bone healing. As with other sleeve injuries achieving a robust, repair at the tendon bone interface without lengthening with non-operative treatment is more unpredictable than tendon-tendon healing. Primary healing of distal injuries can produce bulkier scar tissue which is poorly tolerated over the posterior heel.
    given that the quality of the tendon repair is much more variable than mid-substance ruptures, approximately 90% of patients with sleeve avulsions will have an associated bony prominence or Haglund deformity which will continue to cause symptoms and impingement if not addressed; therefore in active individuals surgery should be considered, as it provides excellent restoration of function in most cases.
    SYMPTOMS & EXAMINATION
    Positive clinical findings are; a gap in the Achilles tendon, an increased angle of declination and a squeeze test open Symmonds’ test that does not produce plantarflexion (Singh: BMJ 2015;351:h4722). Taking note of where the gap in the achilles tendon may raise clinical supicion of an avulsion injury; the defect is located is more distal than expected with a mid-substance tear, at its attachment to the calcaneum.
    The classical presentation occurs in most patients with the sensation of being kicked in the Achilles and on occasion this includes an audible “crack”. Patients are almost always unable to continue any meaningful weight-bearing on the effected leg and a fair degree of swelling and bruising ensues rapidly. The latter in my experience is not an invariable feature. If the Achilles tendon sheath does not rupture(which is an occasional finding at surgery) then any haematoma remains contained, which explains why some cases do not bruise.
    The patient will not be able to perform a single heel rise, but a double heel rise (with weight bearing upon the uninjured side) will be possible and is therefore a useless test to perform. It may be possible to palpate a defect in the tendon but swelling may preclude this. With the patient relaxed and supine gentle dorsi-flexion on the injured side should produce a significant increase in the detectable movement given the Achilles is the major posterior restraint to ankle dorsi-flexion.
    It is worth emphasising that there is an increased incidence of DVT recognised as complicating this injury. The warning sign is usually a change in the status quo. Most patients will suffer venous congestion once the limb is in cast (swelling and colour changes , accentuated when the limb is dependent). An increase in these symptoms or the onset of calf pain (which is not usual after the initial early acute pain of Achilles rupture) should mandate immediate exclusion of DVT.
    IMAGING
    The distal location of the rupture should be confirmed MRI scan or an ultrasound scan, plain X-rays can be useful to exclude associated avulsion fractures. MRI features are often of a sleeve type injury of the tendon insertion
    ALTERNATIVE OPERATIVE TREATMENT
    A flexor hallucis longus (FHL) transfer should be considered in those with severe insertional achilles tendinosis, where the quality of the tendon is likely to compromise function or if this was associated with dysfunction pre-injury.
    An FHL transfer can also be performed in those patients who continue to complain of weakness, dysfunction or pain after operative or non-operative treatment.
    Hamstring grafts have also been reported, however this should be avoided in the serious and elite athlete.
    NON-OPERATIVE MANAGEMENT
    In the less active, those with comorbididties, non-operative management in a walking boot initially fixed in equinus using the same protocol as midsubstance ruptures is reasonable, a degree of residual weakness is better tolerated in this group. In the elderley, if a walking boot will be poorly tolerated, treatment with a light weight AFO can be considered.
    CONTRAINDICATIONS
    Contra-indications to Achilles tendon reattachment include systemic diseases such as poorly controlled diabetes, peripheral neuropathy, peripheral vascular disease, lymphoedema, severe insertional tendinosis, active infection.


    Setup

    Access for repair of an avulsed Achilles tendon will require a longtitudinal posteromedial incision, therefore the patient should be positioned to allow unfettered access to this area. The authors tend to position the patient in a prone position, alternatives are an over-lateral position the operated leg being the lower, or supine with the operated leg held in a figure of 4. A thigh tourniquet is applied before the patient is turned and skin preparation is continued up to the knee to allow access to the calf muscles, which will aid in tensioning and performing an intra-operative squeeze test. The skin is prepared using sterile alcoholic betadine or chlorhexidine.

    Operation – 1

    A posteromedial Skin incision is made approximately 7cm in length.
    This approach is advantagious as it reduces risk of injury to the laterally lying sural nerve, and the slightly medial incision leaves a scar in a less intrusive location with reference to footwear, which can irritate the more posteriorly positioned scar.

    During deep dissection, it is important to develop full thickness skin flaps. This will help preserve vascularity to the skin edges. The posterior tibial neurovascular bundle is located beneath deep fascia. Expose the Achilles tendon and then proceed to develop a surgical plane that preserves any distal tendon that remains attached to the calcaneum.

    The Achilles tendon is prepared, the avulsed Achilles should be exposed and carefully inspected. Small avulsed fragments of bone can be removed, large fracture fragments may require fixation. The quality of the proximal tendon should be assessed, with severe tendinosis, alternative procedures such as an FHL transfer might be preferable.

    Assessing the Achilles insertion:attention is turned to the posterior calcaneum. Any residual Achilles tendon that has not been avulsed with the sleeve and remains attached should be identified, if substantial and good quality this should be used to augment the repair.

    The posterior calcaneum should be assessed for any avulsed bone fragments, and a limited subperiosteal dissection made to allow accurate suture anchor placement.The posterior calcaneum should be assessed for any avulsed bone fragments, in 90% of cases there is a Haglund deformity that should be excised prior to repair.
    Carefully prepare the insertion, with rongeurs or a fine saw to expose bleeding bone allow a well vascularised foot print for tendon to bone healing.

    The elected implantation site, should have good quality bone to provide sound fixation. It should restore physiological length to the Achilles/ Gastrocnemius-Soleus complex.
    Due consideration should be paid to preservation of bone stock, for potential reconstructive procedures that might be needed in the future, such as an FHL tendon transfer.
    Here the tap is being positioned to produce an appropriately orientated bone tunnel.

    The authors tend to use a 5.5mm biocomposite anchor, 4.5mm in smaller individuals.
    A tunnel is made with the punch/tap for the 5.5mm screw., the tip of the device is punched up to the threads and then screwed home up to the laser line.

    The biocomposite Corkscrew FT suture anchor comes preloaded on its introducer, with 4 fibrewire sutures secured to the handle. The units are provided in individual sterile disposable packs.

    The distal stem of the introducer is laser etched with a line to assist in introducing the anchor and ensure it is seated in a recessed position. The anchor should be passed until the laser line is flush with the bone. The anchor is fluted, and is screwed in to place (not hammered or punched)

    The fibrewire sutures are unhitched before removing the introducer.

    Once the sutures have been unhitched from the handle, the introducer can be gently withdrawn, if it doesn’t slide off, gently tapping this with a small hammer can help disengage the driver.

    The biocomposite anchor is passed until buried completely in bone, to the level of the laser line on the screwdriver.

    The 2nd implant is placed to allow as broad a foot print for attachment as possible. Again make sure that it is well seated and not prominent

    Before passing the sutures through the achilles it is vital to get an appreciation of how the tendon will sit relative to the calcaneus.
    With the ankle at neutral, an estimate is made of where the sutures from the anchors should be placed to achieve optimal tension. There is the potential for tendon retraction/relative shortening in longer standing cases in which case the position may need to be adjusted.

    Freshen the deep surface of the proximal tendon, taking care not to sacrifice length, to allow a healthy surface for tendon to bone healing.

    It is often the case, that there is little thickness/structural integrity to the most distal aspect of the avulsed tendon; therefore tis should not be relied upon as the point of primary suture attachment.

    Try to suture into full thickness tendon, leaving the more distal Achilles tissue for subsequent secondary fixation. Leave a sufficient volume of tissue between the 2 fibrewire sutures.

    In suturing the tendon the sutures are passed through to the posterior surface of the tendon but not sutured until all sutures have been passed.

    Continue to place fibrewire sutures into well spaced points of good quality tendon.

    Suture postioning: The 2 Fibrewire sutures x4 have been distributed across the width of the tendon.
    This allows a broader foot print of attachment to the recipient surface of the calcaneum.

    When re-attaching the achilles progressively tie off the sutures.
    It is helpful to tie these with the ankle in slight plantar flexion, whilst continuing to check that tension is optimal.
    Occasionally sutures can cut through or snap, these should be replaced.

    Assess the interface between most distal avulsed tendon and the remaining attached Achilles. This is thinner and poorer quality tissue but is very important as a point of secondary attachment, an will achieve potentially stronger tendon on tendon healing.

    Excise bulky edges that are not repairable in order to reduce bulk around the insertion.

    Repair the distal portion of the avulsed Achilles to the intact portions of the distal tendon tissue, and to the periosteum. Use a ‘0’ or ‘1’ vicryl tie these off, leaving as neat a seam as possible. leave the sutures long for the next step.

    using a Mayo needle, pass both ends of the locked Vicryl suture into the Achilles insertion to undersew, and reduce profile of the suture knot.

    Operation – 2

    Often there is sufficient room for 3 or 4 sutures.

    Once the repair appears sound, a final tension test should be performed.The ankle should be gently dorsiflexed to assess the integrity of the repair, taking care not to overstrain the interface.

    Trim any excess tissue, which may lead to an over-bulky repair.Further excess is trimmed.

    Finally a running O Vicryl suture is passed to further strengthen the repair and make the suture line less prominent.

    All sutures then trimmed.

    Post Operative

    The ankle is immobilised in 20 degrees of plantar flexion in a plaster of Paris for two weeks.
    Appropriate low molecular weight heparin is used for thromboprophylaxis.
    At two weeks the sutures are removed and if the wound is healing well, patients are placed into a variable angle walking boot in 20 degrees plantar-flexion. The boot is unlocked by 5 degrees each week reaching the final position, plantigrade at six weeks. The boot is worn in plantigrade for a further 6 weeks. Fully weight bearing is encouraged as soon as the patients are placed in The Walking boot. From two weeks the boot can removed when at rest for gentle mobilisation; initially gentle dorsiflexion exercises. At four weeks they begin plantar-flexion exercises against gravity and a six weeks gentle resistance is added. The Walking boot is removed at 12 weeks by which time, bilateral heel raise exercises have been introduced. For 4 weeks a small heel raise is worn within the shoe.
    Controlled, low impact activity exercise such as cycling and swimming is encouraged from 12 weeks; however running or impact activity should not begin before four months. Return to contact sports is generally not advised for a minimum of 6 months. A number of studies suggest that it will often take two years before athletes have attained to the pre injury level of sporting function and metrics. A proportion of patients will fail to return to their pre-injury function.

    Recommended Reading

    Tendon to bone healing and its implications for surgery
    D Bunker, V Ilie, S Nicklin
    Muscles Ligaments Tendons J. 2014 Jul-Sep; 4(3): 343–350.
    Concludes that many injuries occur at the tendon bone interface and that the repair of these injuries is inferior to tendon-tendon healing and is partly reliant on the healing of the surrounding soft tissues. There is some evidence that initial immobilisation followed by gentle mobilisation can improve the quality of repair.

    Primary repair of Achilles tendon avulsions: Presentation of a novel technique and its comparison with suture anchor repair
    Ç Işık, M Tahta
    Journal of Orthopaedic Surgery. November 14, 2017
    A retrospective study looking at 21 patients; 12 with bone sutures and 9 with a novel suture anchor technique. Both techniques provided reliable repair of Achilles tendon avulsions.

    Characterization and Surgical Management of Achilles Tendon Sleeve Avulsions
    Jeannie Huh, MD, Mark E. Easley, MD, James A. Nunley, II, MD
    Foot & Ankle International: February 3, 2016
    A retrospective study looking at the characteristics and management of 11 sleeve avulsion injuries of the Achilles insertion. The authors acknowledge this is a relatively rare injury pattern and is challenging to treat with insufficient tendon to allow for an end-to-end repair and unlike a tuberosity avulsion fracture any avulsed bone is insufficient for internal fixation.
    They noted that 10 of the 11 patients were male and a number had pre-existing symptoms of insertional tendinosis. 10 of the injuries were sustained during recreational activity and 4 were not recognised preoperatively. 90% of the avulsions had an associated Haglund deformity and macroscopic evidence of insertional tendinopathy .
    All patients healed after suture anchor repair 10 patients were completely satisfied. They concluded that Achilles tendon sleeve injuries were most common in middle aged man with pre-existing insertional disease, sustained during athletic activity. Suture anchor fixation combined with excision of bony prominence at the insertion was a reliable and safe technique. The majority of patients returned to their pre-injury levels of recreational activity and work

    Avulsion Fracture of the Calcaneal Tuberosity: Classification and Its Characteristics
    S Lee, S Huh, J Chung, D Kim, Y Kim, S Rhee
    Clin Orthop Surg 2012 Jun;4(2):134-8.
    Assessed 764 calcaneal avulsion fractures classified these into four subtypes which is a revision of the Beavis classification There is a degree of overlap with the avulsion fractures and Achilles tendon sleeve injuries.

    Repair of the Achilles Tendon Sleeve Avulsion: Quantitative and Functional Evaluation of a Transcalcaneal Suture Technique
    C Bibbo, R Anderson, W Hodges Davis, M Agnone
    Foot Ankle Int 2003 Jul;24(7):539-44
    Transosseous suture of avulsed Achilles insertion provides good functional outcomes and strength testing on the cybex machine showed no statistically significant difference between the injured and an injured limb.

    Acute Achilles tendon rupture.
    Singh D. BMJ. 2015 Oct 22;351
    Defines the most accurate clinical tests for diagnosis of an acute Achilles tendon rupture is a triad of: palpable gap, a positive Simmonds’ test with reduced foot plantar flexion during calf squeeze, and an increased angle of declination of the foot compared to the opposite side when the patient is lying prone.

    Reference

    • orthoracle.com

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