Minimally Invasive Achilles Tendon Repair
Advancements in tethering material has led to the development of FiberWire, which is the suturing material utilized in most modern day achilles repair system. FiberWire is constructed of a multi-strand, long chain ultra-high molecular weight polyethylene core with a braided jacket of polyester.
Although open techniques have historically been utilized for the repair, this approach is often complicated by wound-healing issues and infection, as the skin in the area of the achilles tendon is under high tension. This led to the development of achilles repair systems that are able to achieve equivalent load-failure strength through a percutaneous and minimally invasive surgical incisions.
This has shown to significantly mitigate the risk of wound healing complications including delayed healing, adhesions, and unsightly scaring. However, there does exist a slightly higher risk of damaging the nerve that provides sensation to lateral aspect of the foot and ankle with this technique.
Achilles Tendon Repair
Success of an achilles tendon repair relies on securing the ruptured ends of the tendon back together. This has traditionally been accomplished by making a large incision to expose the entire damaged section of the tendon (i.e. an “open” approach) and then sewing (i.e. suturing) the two ends back together.
There exists a large variety of suture material that has been used for this procedure. Suture material generally exists in two forms, absorbable and non-absorbable, both of which have been used for achilles tendon repair.
Non-absorbable suture is most often utilized in this setting as it has demonstrated superior load-to-failure strength compared to absorbable suture. There also exists a large variety of techniques for securing the two ends of the suture together.
Achilles Tendon Rupture
Achilles tendon ruptures are a common injury in elite and recreational athletes, most often occurring in men aged 30-40. Risk factors are episodic athletes (“Weekend Warriors”), active use of fluoroquinolone antibiotics, and history of steroid injections into the achilles tendon. This injury occurs after forceful plantar flexion during a sporting event, or violent dorsiflexion against a plantarflexed foot.
Ruptures typically occur 4-6cm above the calcaneal (heel bone) insertion in the hypovascular region (i.e. low blood flow) area of the tendon. Patients often experience an audible “pop” and will have difficulty plantarflexing the foot. These are typically a degenerative injury, meaning the tendon has sustained repetitive microtrauma over a matter of years with subsequent inflammation that ultimately weakens the tendon to the point of rupture. While the option to treat these without surgery exists, some patients may elect for operative repair.
Historically, operative repair was associated with a lower risk of re-rupture. Although newer studies have shown that dedicated rehabilitation may offer similar risks or re-rupture and as well as ultimate strength, surgical repair offers the opportunity of a quicker recovery and a more convenient rehabilitation regimen.
The Arthrex PARS Achilles Jig System is utilized in a percutaneous and minimally invasive surgical approach to reduce the risk of wound complications. The healed tendon achieves a more natural contour, unlike the typical hypertrophic tendon resulting from open repair.
This system utilizes fiber wire for the suturing material used to secure the ruptured ends of the tendon together. The jig apparatus provides the option of utilizes transverse and locking sutures, and both techniques can be used simultaneously. The locking option allows the surgeon to incorporate a locked FiberWire suture on both ends of the ruptured tendon.
Biomechanical studies have demonstrated that the locking technique results in a stronger repair than just passing transverse sutures across the tendon like other minimally invasive technologies used in today’s practice. The jig apparatus that is utilized during the repair also provides consistent and reliable capture of the proximal and distal aspects of the tendon, as compared to “free-handing” the suture through the tendon that is part of the more traditional technique used for repair.