Minimally Invasive Techniques: Fewer Complications, Better Result Phinit Phisitkul, MD
Disclaimer Arthrex: Consultant Smith & Nephew: Consultant Mortise Medical: Stock First Ray: Stock
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
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