Jigless knotless internal brace technique for acute Achilles tendon rupture: a case series study

Written informed consent was obtained from all patients. All procedures were approved by the National Cheng Kung University Hospital’s (NCKUH) Institutional Review Board. Consecutive patients treated for acute Achilles tendon injury at NCKUH between January 2015 and July 2017were evaluated. Our inclusion criteria were a positive Simmonds test (aka Thompson test or Simmonds-Thompson test) and a palpable defect in the Achilles tendon corresponding to a midsubstance rupture. Surgery occurred within 2 weeks post-injury. The exclusion criteria were a cutting or penetrating injury, an injury more than 2 weeks old, a neurological or a psychiatric disorder, pregnancy, being less than 18 years old, an incomplete medical record, an inadequate follow-up, autoimmune or connective tissue diseases (e.g., rheumatoid arthritis), radiotherapy or chemotherapy, morbid obesity, and previous Achilles tendon surgery. Finally, 10 patients (men, 9; women, 1; minimum follow-up, 1 year; mean age, 37.3 years; age range, 20–53 years; mean body mass index [BMI], 24.5; BMI range, 22.1–29.7) were enrolled. All enrolled patients had undergone the same post-operative rehabilitation protocol, and all returned to our hospital for clinical follow-ups 2, 4, 6, and 8 weeks, and 3, 4, 6, and 12 months post-surgery.

After a patient had been spinally anesthetized, they were put on the table in the prone position, and an air tourniquet was placed on the thigh. The tendon gap was palpated to identify the ruptured end. A 3-cm long transverse incision was made 2 cm proximal to the ruptured end. The proximal stump was gently pulled out through the transverse incision with the knee in flexion position after the stump had been freed from the surrounding paratenon and plantaris tendon, if it was present, using a 1-inch ribbon malleable retractor. The hematoma was completely debrided. Krackow locking loops were used on both sides of the soleus muscle and healthy tendon of the proximal stump (Hi-Fi® Suture; CONMED Corporate Headquarters, Utica, NY, USA) (Fig. 1a, d). An Allis clamp (forceps) was subcutaneously inserted through the transverse incision in maximum ankle plantar flexion to maintain the tension of the distal stump, and then the percutaneous suture was crisscrossed through the distal stump (CONMED) (Fig. 1b, d). The end of the distal stump suture was subcutaneously passed through the transverse incision (Fig. 1c) and then looped through the proximal stump Krackow locking loop as the pulley (Fig. 2a, d). Two 0.5-cm long vertical incisions were bilaterally made on the posterior calcaneal tuberosity, and then the bird-beak arthroscopic suture passer was subcutaneously passed from the vertical incision to the transverse incision (Fig. 2b, d). The subcutaneous tunnel must be empty to avoid skin dimpling in the subsequent suture passage. The ipsilateral Krackow suture end and contralateral crisscross suture end were passed down to the distal mini-vertical incision (Fig. 2c). The sutures were seated at the posterior calcaneal tuberosity with two 4.5-mm suture anchors (PopLok® Knotless Suture Anchors; CONMED) (Fig. 3a, d). The tendon rupture gap became smooth and impalpable when the sutures were pulled to symmetrically proper tension in 30° of knee flexion and ankle plantar flexion. The anchors were then locked. A 3-0 absorbable running stitch (Monocryl; Ethicon, Johnson & Johnson Medical N.V., Belgium) was used at the epitenon (Fig. 3b). The wound was irrigated and closed layer by layer with 3-0 and 4-0 monocryl subcutaneous sutures and finally closed with reinforced antimicrobial skin closures (Steri-Strips; 3 M Health Care, St. Paul, MN, USA). The Achilles tendon tension was checked with the leg erect immediately post-surgery (Fig. 3c).

The mean time between injury and surgery was 4.3 days (range, 1–9 days). The mean surgery duration was 22 min (range, 18–36 min). The transverse incision averaged 6.3 cm (range, 5.5–7 cm) proximal to the calcaneal tuberosity.

There were no serious complications in the present study. All incisions healed well and without scar adhesions or superficial or deep infections (Fig. 4a). There were no sural nerve injuries, reruptures, deep vein thromboses, or pulmonary embolisms.

After 1 post-operative year, all 10 patients scored 100 points on the American Orthopaedic Foot and Ankle Society (AOFAS) scale, and they returned to their preoperative exercise levels. Patients needed a mean of 7.5 days (range, 3–11 days) to walk FWB without crutches and they needed a mean of 24.5 days (range, 21–28 days) to walk with a full ankle-joint range of motion (Fig. 4b, c). To stand with a raised heel without an aid, they needed an average of 35 days (range, 28–42 days) (Fig. 4d). All patients returned to their jobs, which needed an average of 45.5 days (range, 35–63 days), and to their previous athletic exercise level, which needed a mean of 147.5 days (range, 84–210 days).