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Achilles tendon rupture- Integra Achillon percutaneous repair

    Overview

    Learn the Achilles tendon rupture: Integra Achillon percutaneous repair surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Achilles tendon rupture: Integra Achillon percutaneous repair surgical procedure.
    Operative repair of the acutely ruptured Achilles tendon allows controlled apposition of the tendon ends and restoration of the normal length of the triceps surae musculo-tendinous unit.
    This may be the preferred method of treatment in active patients and in those patients where the gap between the tendon ends does not close sufficiently with the ankle placed into maximal plantar-flexion (as assessed on a pre-operative ultrasound scan).
    The Integra Achillon limited open repair technique permits direct visualisation and apposition of the ruptured Achilles tendon ends whilst limiting the extent of the soft tissue dissection. It has the benefit of using a much smaller incision than conventional open repair techniques which probably provides advantage with respect to superficial wound complications. It also has the benefit of being one of the systems with the longest track-record for minimally invasive Achilles repair.
    The published results using the Integra Achillon emphasise the need for careful execution of technique and in particular placement of the Achillon jig between the discreetly dissected layers of the fascia cruris and paratenon to minimise the chance of Sural nerve injury. The key papers to be read are: Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. Assal M et al. JBJS (Am) 2002; 84: 161-70, Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Calder JD, Saxby TS. Br J Sports Med 2005; 39: 857-9 and Outcome following use of the Achillon jig for the repair of acutely ruptured Achilles tendons. Davies H, Agrawal Y, Blundell C, Davies MB. Injury 2017; 48: 781-3.

    Indications

    INDICATIONS
    Acute rupture of the Achilles tendon: With confirmation of the diagnosis on an ultrasound scan, the gap between the tendon ends can be assessed to see if the tendon ends can be apposed. If with the foot in full plantarflexion, a gap of greater than 10mm exists between the tendon ends, then in my practice, this warrants surgical repair. The definition of acute is debatable but it is possible to use the Achillon technique to achieve tendon end apposition in patients with mobile tendon segments up to 3 weeks from injury.
    The Achillon technique can be used in proximal Achilles tendon ruptures (less than or equal to 10cm from the calcaneal insertion.
    SYMPTOMS & EXAMINATION
    The classic patient is a male between the ages of 25 and 55 years who is involved in a lunging movement whilst taking part in sports. The symptoms are of an acute pain in the back of the heel and the patient often believes he has been struck from behind by another player. The patient is seldom able to complete the sporting activity and notices an abnormal posture within the foot and ankle with accompanying swelling and usually (though not always) bruising.
    Examination is best performed with the patient either kneeling on a chair supporting themselves on the chair back or with the patient lying prone on a couch with their knees bent to 90 degrees. Inspection reveals a swollen distal portion of the leg and the characteristic difference in foot position between the injured and uninjured limbs owing to the effect of gravity on the foot position. The normal limb shows the foot rests in a position of plantarflexion whilst the injured limb rests with the foot often appearing to be plantigrade or even in dorsiflexion at the ankle. Inspection also reveals any evidence of previous surgical scars which may influence choice of treatment.
    Squeezing the muscle bellies of the gastro-soleus should invoke the foot to plantarflex indicating an intact Achilles on the normal limb. Repeating this manoeuvre on the injured side reveals no foot movement.
    IMAGING
    Ultrasound is the investigation of choice. It allows assessment of the tendon quality (revealing underlying tendinopathy), the site of the rupture (the distance from the insertion on the calcaneus) and whether or not the tendon ends can be apposed. Determination of the site of rupture is helpful because ruptures proximal to the myotendinous junction do not require operative intervention.
    Plain radiography is indicated if the suspected site of the rupture lies close to the calcaneal insertion as management of a bony avulsion of the Achilles insertion is a separate entity.
    ALTERNATIVE OPERATIVE TREATMENT
    Standard open repair techniques have more of a role in managing delayed diagnosis of Achilles rupture. Delayed presentation of more than 6 weeks may mean that the open repair technique will involve additional adjunct procedures such as transfer of the tendon of FHL to the posterior calcaneus or techniques of advancing the proximal Achilles tendon stump using V-Y plasty or turn-down techniques.
    Percutaneous operative repair techniques: Several techniques have been described with no particular technique gaining widespread use.
    NON-OPERATIVE MANAGEMENT
    Recent studies in the literature support the treatment of closed acute Achilles tendon ruptures with apposable tendon ends in a weight bearing walker boot. The boots either have adjustable hinges at the ankle to vary the degree of equinus or, more commonly, removable wedges can be applied within the boot to adjust the foot position.
    CONTRAINDICATIONS
    The absolute contraindication for surgical repair of an Achilles rupture is in patients with poor lower limb vascularity. Patients with underlying neuropathy and diabetes should also be preferentially managed non-operatively. Any patient taking medications that compromise the immune response to trauma (steroids, DMARDS etc) should avoid surgical repair.
    Patients who are very swollen or in whom the tendon ends are not readily palpable can still be treated using the Achillon device but I would suggest that the position of the distal extent of the proximal Achilles stump is determined on ultrasound and the skin marked before proceeding to surgery.

    Setup

    The patient is best positioned fully prone with the use of a thigh tourniquet. An adhesive drape excludes the tourniquet from contact with the preparation agent. The foot should be placed on pillows and is often best hanging free over the end of the operating table.
    Routine use of a single dose of prophylactic antibiotics is recommended.

    Operation – 1

    Position the patient prone on the operating table with the foot lying free.
    With the patient positioned prone, it is clear that there is a difference in foot position of the ruptured right Achilles tendon compared to the normal calf tension seen in the left Achilles.

    Palpate the gap between the tendon ends.The gap between the tendon ends is palpated.

    Mark a transverse skin incision lying closer to the proximal tendon stump.A transverse incision is marked on the skin closer to the proximal tendon end than the distal tendon end. This is because the distal tendon end can always be delivered into the surgical wound. The advantage of the transverse incision is that it lies within Langer’s lines and heals readily. It almost always lies proximal to the backs of most shoes meaning that it is more comfortable to recover from. However, this wound cannot be extended. The length of the transverse incision should allow access to the medial and lateral extent of the paratenon. The variable course of the sural nerve means that it may be close to the lateral side of the incision.
    It is worth noting that the original Achillon surgical technique describes the use of a longitudinal skin incision. The longitudinal incision is best placed slightly medial to the midline to reduce the chance of injuring the sural nerve. The longitudinal incision also has the advantage of being extendable which may be of use in treating very swollen ruptures where the tendon gap is indistinct.
    When learning this technique using the transverse incision, it is possible to make the skin incision too distal to allow easy access to the proximal tendon stump. Because this incision is not extensile, the easiest way to retrieve the situation is to make a parallel incision 3-4cm more proximal and retrieve the tendon.

    Incise the skin taking care laterally not to injure the sural nerve.The skin incision is made taking care with deepening to protect the sural nerve that may lie in the lateral extent of the wound.

    Expose the underlying paratenon.The fat is divided in line with the incision to reveal the paratenon.

    Divide the paratenon in line with the skin incision.Using sharp dissection, the paratenon is opened transversely in line with the skin incision. This will release the significant haematoma from the site of injury. Be aware that the paratenon may appear to form two distinct layers as the overlying fascia cruris can blend into the tendon sheath (see Results section).

    Gain control of the proximal stump using tissue forceps.The proximal stump is addressed first. Sweep your finger around the stump to mobilise it. Then obtain a firm grip on the tendon end using a ratcheted tissue forcep.
    Note that the two Langenbeck retractors are hooked into the corners of the wound and their tips form the boundary of the paratenon.

    Set the Achilles jig up so that it is freely mobile and able to accommodate variable tendon widths.This is the Achillon jig. It consists of two mobile segments joined by a connecting bolt. Each segment has two prongs that each have three holes in their ends. The two innermost prongs (A) will be applied either side of the tendon end and MUST lie within the paratenon. The two innermost prongs can be separated and adjusted to accommodate the tendon between their tips using the knurled knob (B) on the end of the connecting bolt.

    Maintaining traction on the tendon stump, introduce the Achillon jig deep to the paratenon.Maintaining gentle traction on the tissue forceps so that the tendon is not pushed deep as the jig is advanced, the jig is inserted so the the inner prongs accommodate the tendon stump between their tips but also that they are advanced within the paratenon sheath. In this way, the sural nerve should be protected from injury as all suture material and knots will lie between the tendon bulk and the paratenon.

    Advance the jig to its hilt.The jig is advanced to its hilt making sure that the tendon stump remains visible and palpable between the inner prongs.

    Confirm the tendon ends lie between the prongs of the jig and advance the most proximal threaded needle through the holes in the jig.After confirmation that the proximal tendon stump lies between the inner prongs, the first suture is threaded through the eye of the needle provided with the jig (Remember to ask the scrub nurse to cut off the needles that come attached to the suture).This is easiest passed from lateral to medial and using the hole in the jig furthest from the skin incision.

    Pull the suture material through the jig. Repeat the process for the remaining two sutures in the proximal stump.The needle will pass the suture through all four holes in the jig. On occasions in tough skinned individuals, a “thimble” device supplied with the jig can be used to comfortably pass the suture. The needle should be pulled through the medial skin so that a suture thread passes from lateral to medial.

    The procedure is repeated using different coloured, heavy gauge suture materials in each hole of the jig. In this case, a number 2 Ethibond suture (green) is passed furthest from the incision. The suture passing through the middle holes is a number 1 PDS (black) and a number 1 Ethilon (blue) is passed through the holes nearest the skin incision. The colour coding permits easy pairing of the sutures later in the procedure.

    Withdraw the jig carefully.The soft tissue forceps are then removed to permit careful withdrawal of the jig from the wound.

    Gather the innermost suture ends.The surgeon then gathers the six suture strands that will lie either side of the tendon stump. Three come from each inner prong and will contain the three different suture colours.

    Test the hold within the tendon by applying gentle traction.The two groups of three sutures are then bundled together and the surgeon can pull on the bundles to see if they have a satisfactory hold on the tendon stump. Each suture bundle is then clipped together whilst attention turns to the distal tendon stump.

    Repeat the process to the distal stump, commencing with applying a tissue forcep to the tendon stump.Exactly the same steps of the procedure are repeated – tissue forceps control of the distal tendon stump followed by protection of the paratenon edges.
    Tip – the distal stump can be delivered into the wound by plantar flexing the foot.

    Pass the Achilles jig distally.Keeping control of the tendon stump, the Achillon jig is inserted to engage the distal tendon stump.

    Sequentially pass the three sutures starting from distal to proximal.The same sutures are passed again taking care to pass the number 2 Ethibond suture (green) through the holes in the jig furthest from the incision followed by passing the number 1 PDS (black) through the middle holes and a number 1 Ethilon (blue) through the holes nearest the skin incision.

    Withdraw the jig and gather up the innermost suture material.The tissue forcep is released and the jig is withdrawn from the wound. The two groups of three sutures are then bundled together and the surgeon can pull on the bundles to see if they have a satisfactory hold on the tendon stump. Each suture bundle is then clipped together.

    Test the hold within the distal tendon stump.Pulling on both of these suture bundles shows good hold in the distal stump and should allow the surgeon to lift the foot in the air to demonstrate this.

    This results in four bundles of three suture strands, two for each tendon end and lying each side of the tendon.

    Join each reciprocal suture by tying the suture loosely.The sutures are tied sequentially starting with the sutures passed furthest from the wound and finishing with the sutures that were passed closest to the wound (as follows): Each green number 2 Ethibond suture is then released from the bundle. The two medial suture ends need to be tied together.

    It is crucial to tie these knots securely so I lay the knots on a finger to make sure that no slip knots are inadvertently tied.

    Snug that knot against the tendon and tie the other reciprocal suture end. Repeat the process for each remaining pair of sutures.Having secured the knot medially, the lateral ends of the number 2 Ethibond can be tied together. This is best done by asking the the scrub nurse to lift the foot into full equinus whilst the two suture ends are tied with a double throw and carefully laid. The knot on the medial side will disappear from view and can be manoeuvred away from the wound edges. Once the lateral knot is first thrown, it is a good idea to hold the knot with a forceps before completing remaining throws and preserving the tension in the knots and the tendon end apposition.
    If when tying the knots, the suture material snaps, it is relatively straightforward to pass the jig again and pass another suture to restore the compliment of three sutures in each tendon end.

    Operation – 2

    The same steps are used to throw the black and blue suture ends.

    Test the tendon repair is intact by squeezing the calf and make sure the foot does not lie in excessive equinus.It is important to repeat the calf squeeze test at the end of the procedure to demonstrate restoration of tendon continuity.

    Close the paratenon.The paratenon ends are then closed over the repair making sure that all knots are well covered.

    Close the skin.The paratenon is closed with 2-0 Vicryl.

    A subcuticular closure of the skin is performed with 3-0 Monocryl. The length of the incision can be gauged from this photograph.

    The transverse wound and needle puncture holes can be appreciated with this image.

    Apply a complete fibreglass cast in a mid-equinus position.Additionally, the foot should lie in an optimal position to allow for early rehabilitation so a cast is applied in a mid-equinus position.

    Position of foot in a complete synthetic cast.

    Post Operative

    The below the knee complete cast is kept in place for 2 weeks after surgery during which time the patient is not able to bear weight through the cast. This allows the wound to settle. At two weeks, the cast is removed and the wound inspected and, if need be, re-dressed with a dry adhesive dressing.
    The patient is then transferred to a walking boot with three heel wedges inserted. They are permitted to walk on the boot and instructed to remove one wedge per week so that at the 6 week review, they will have been plantigrade in the walker boot for one week. At the 6 week review, the boot is removed and the patient is referred for physiotherapy and supplied with a heel lift for their shoes. Physiotherapy requirements vary from patient to patient and most will make sufficient progress such that discharge from the fracture clinic can occur at week 12 post-op. Patients are encouraged to make gentle return to sporting activities after their discharge from the fracture clinic. Physiotherapy usually continues until patients achieve an active single stance heel raise which usually occurs by week 20. One key tenet of the rehabilitation protocol is for the patient to avoid forced dorsiflexion exercise within the first 3 months of surgical repair.
    Note that my practice is to provide 6 weeks of oral thromboprophylaxis (Rivaroxaban) in the post-op period because of the higher risk of thrombi-embolic events occurring with these injuries.

    Recommended Reading

    There are three papers specifically assessing the results of the Achillon technique. The first is a paper by the developer of the technique, Dr M Assal, detailing the initial cadaveric study and a prospective clinical series. The second documents an independent series of Achilles ruptures treated with the Achillon jig and describing the use of a transverse incision. The third paper, independent of the jig designers, documents a longer term follow-up of a larger series also using the transverse incision.
    Key papers comparing non-operative management vs operative management have been quoted elsewhere in this atlas by Mr Mark Herron when dealing with the standard open repair technique.

    Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. Assal M et al. JBJS (Am) 2002; 84: 161-70.
    A cadaveric study was performed using the jig to ascertain the vulnerability of the sural nerve to injury from the suture needles. Following this, a large number of patients were prospectively treated in a multi-centre study. With a decent follow-up rate beyond two years, patients were seen to recover excellent functional scores. There were no documented infections nor sural nerve injuries but re-rupture was noted.
    Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Calder JD, Saxby TS. Br J Sports Med 2005; 39: 857-9.
    A good-sized cohort of patients were prospectively followed up for 12 months after having had the Achillon jig to repair their acute tendon rupture. This paper described the use of the technique through a transverse skin incision. All scored well with recognised scoring systems. Within the cohort, one had a superficial wound infection and two had sural nerve neurapraxias. There were no documented re-ruptures.
    Outcome following use of the Achillon jig for the repair of acutely ruptured Achilles tendons. Davies H, Agrawal Y, Blundell C, Davies MB. Injury 2017; 48: 781-3.
    A large series of patients were retrospectively assessed with a case note review and postal scoring. The technique was practised in one institution by a mixture of general trauma surgeons and dedicated foot and ankle surgeons. With over 2 years of follow-up there was a wider range of functional outcome scores than in the previous studies. The study details possible complications of thrombi-embolic disease, superficial and deep wound infections and sural nerve injuries. The study emphasises the need to be vigilant for discrete, separate layers of the fascia cruris and paratenon as the jig can still injure the sural nerve if inserted between the paratenon and the fascia cruris.

    Reference

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