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Some New
Considerations By Jay
Lieberman, DPM
A five year old female presented to our emergency room with a laceration of the left posterior heel. The injury occurred when the child fell from her bike and her ankle became trapped in the spokes of the wheel. On initial inspection, the injury did not appear to too severe. However, once the site of the injury was regionally anesthetized and more closely examined, it became apparent that the Achilles tendon was lacerated. The Thompson squeeze test was positive and a palpable defect was noted. We felt that the best functional outcome could be achieved through surgical repair. Intra operatively, the original laceration was extended 4 cm proximally and 2 cm distally. The tendon was found to have retracted 3 cm. Typically, Achilles tendon ruptures have a frayed appearance. In this case, the tendon was cleanly severed as though cut by a surgical incision. To facilitate approximation of the tendon, the knee was flexed and the ankle was dorsiflexed. We used a Keith Needle passed through the midbody of the proximal segment (medial to lateral) to distract and resist retraction of the tendon.
This approach facilitated anastomosis of the tendon segments. In this case we used a Bunnell stitch; however we have since found the Krackow stitch to be more secure.
Bunnell Stitch
Krackow Stitch A frustrating complication of this approach is the occasional tear of the suture, just prior to closure, or during the initial post operative period.
I was recently introduced to a new device which offers the benefit of being minimally invasive.
It uses three size "O" sutures which are decidedly more secure than the one suture described above. An anastomosis can often be achieved through a 1.5 - 2.0 cm incision. The Achillon� System� is indicated for acute ruptures lacerated between 2 and 8 cm above the calcaneus. Contraindications include chronic or neglected ruptures and previous local surgery. SURGICAL TECHNIQUE The Surgical Technique is described in more detail at https://www.integra-ls.com/PDFs/newdeal/achillonst.pdf . Another source of information on this procedure can be found in the Journal or Bone and Joint Surgery https://www.ejbjs.org/cgi/content/abstract/84/2/161 Here is a brief overview: A 1.5 - 2 cm incision is made vertical and medial to the tendon, proximal to the palpable dell (soft spot). Another small incision is then made in the paratenon. The next step is to bluntly dissect the paratenon from the tendon to create a small tunnel. The "V" shaped central arm of the Achillon� is introduced in the closed position, under the paratenon, proximally.
The Achillon� is progressively widened so the tendon eventually falls between the two "V" shaped central arms. The two outer arms remain outside the skin. Once proper positioning has been confirmed, the needle driver is used to pass suture material through the instrument, through the skin, and through the midbody of the tendon.
Once three sutures have been passed through the tendon, the instrument is withdrawn. From an extra cutaneous position, the sutures become subperitendinous. Thus, the tendon itself becomes the only site of tissue attachment for the suture.
The procedure is repeated on the distal stump and the anastomosis is completed.
The Achillon� is a minimally invasive approach to Achilles tendon ruptures. Patients will invariably recover faster and appreciate the cosmesis of a smaller scar.
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