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Minimally Invasive Techniques: Fewer Complications, Better Result Phinit Phisitkul, MD

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Achilles tendon repair  Elegant surgical dissection ??

 Wound complications !!!!! (up to 34.1%) Treatment of Acute Achilles Tendon Ruptures. A Meta-Analysis of Randomized, Controlled Trials. Riaz J.K. Khan et al. J Bone Joint Surg Am, 2005 Oct; 87 (10): 2202 -2210 .

Surgical vs Nonsurgical  60 patients, Functional rehab vs open repair  Superior “Peak torque” of 14% at 18 months (p= 0.022)  Superior RAND 36 PF and Bodily Pain  Iikka Lantto,* MD, Juuso Heikkinen,* MD, Tapio Flinkkila,* MD, PhD, Pasi Ohtonen,* MSc, Pertti Siira,y PT, Vesa Laine,y MSc, and Juhana Leppilahti,*z MD, PhD Oulu University Hospital, Oulu, Finland

Minimal Invasive Repair  Achillon  PARs  Ma/Griffith Ozsoy et al, FAI 2013  Maffulli  Endoscopic  etc. (Guillo et al 2013 Surgeon) Kupcha et al, AJO 2008

 6 RCTs, 277 repairs  No difference: re-rupture, tissue adhesion, sural nerve injury, deep infection, deep vein thrombosis  MIS: reduced superficial wound infection, 3 times greater patient satisfaction

 12 studies, 5 RCTs, 781 patients  Comparable: clinical and functional outcomes  MIS: less re-rupture rate, deep and superficial infections, wound disorders, hospitalization time, return to work  MIS: more neurological complications

Sural Nerve !! Risk of injury -Neutral 14.8% -Internal rotation 25.6% -External rotation 0% (Aibinder FAI 2013) 0% Nerve injury (Hsu FAI 2015)

Endoscopic Achilles Tendon Repair  Indication: Acute Achilles tendon rupture within 2 weeks Percutaneous suturing of the ruptured Achilles tendon with endoscopic  control. Doral MN, Arch Orthop Trauma Surg. 2009 Aug;129(8):1093-101. Repair of achilles tendon rupture under endoscopic control. Fortis AP  Arthroscopy. 2008 Jun;24(6):683-8. Arthroscopically assisted percutaneous repair of fresh closed achilles  tendon rupture by Kessler's suture. Tang KL, Am J Sports Med. 2007 Apr;35(4):589-96.

Techniques (modified Ma & Griffith)  Six stab incisions  No 2 fiberwire, 4 strands repair  Arthroscopy for identifying soft tissue plane and avoiding sural nerve.

Results  Halasi, KSSTA 2003: 67 patients, F/U 12-60 months, mean plantarflexion strength 86%, good to excellent 89%, DVT 1, partial rerupture 1  Doral MN, Arch Orthop Trauma Surg. 2009 62 patients, 2 transient sural hypoesthesia, 95% returned to sports, Mean post-op AOFAS ankle- hindfoot 94.6. No re-ruptures, deep venous thrombosis or wound problems

Personal Experience  32 patients between 2008-2015  Mean f/u 4 years  Average tourniquet time 40 mins  Significant improvement in VAS, SF-36, FAAM  Return to sports at 3.6 months  Tendon enlargement 9.4%, superficial infection 3%, Sural neuritis 0% so far Accepted: Arthroscopy 2017

Thank you