This is my retrospective study on the mini-open repair technique for acute Achilles tendon ruptures.

3. Overview Purpose Methods Statistical Analysis Procedure Results Discussion

4. Purpose There is a recent report favoring non-operative treatment for acute Achilles tendon ruptures1 The consensus in the literature favors operative treatment.

5. Purpose Most studies have shown surgical intervention produces few complications and less re-rupture Athletes regain ~50% of post-injury power after tendon repair.11 32% of NFL players do not return to sport

6. Purpose More recently, a single incision (mini-open) technique has been reported2-4. Our retrospective series aims to report outcomes using this mini-open technique over the last eight years.

7. Purpose RETROSPECTIVE CASE SERIES Level of evidence: IV (Therapeutic)

8. Methods Reviewed the medical records for 40 consecutive patients who underwent an Achilles tendon repair between January 2002 and December 2009 There were 19 patients (19 cases) who underwent a mini-open technique. Followed for an average of 24.4 months (range 12 to 68 months).

9. Methods All patients were assessed clinically Victorian Institute of Sports Assessment - Achilles (VISA-A) score5 Visual Analog Pain Scale (VAS) Any post-operative complications and re-ruptures was also recorded.

10. Statistical Analysis A paired student t-test was used to determine significance between pre-operative and post-operative outcomes with p < 0.01.

11. Procedure An incision is placed ~1cm proximal to palpable dell

12. Procedure Advance the jig with inner arms along the paratenon

13. Procedure Pass the guide pins with suture through the jig designated hole-design

14. Procedure Once all sutures have been passed through, slide jig out

15. Procedure Place jig into distal part of incision and repeat prior steps

16. Procedure With foot in maximum plantarflexion, hand-tie sutures on medial and lateral side at the same time.

17. Procedure Closure/casting The paratenon and skin is closed with absorbable suture. A short leg cast at 20 degrees of equinus, and the patient is instructed to be non-weight bearing with crutch assistance.

18. Procedure Post-operative After two weeks post operative, the patient is transitioned into a walking boot. The gradual reduction of equinus performed utilizing removable heel lifts. Physical therapy exercises initiated upon removal of the short leg cast.

19. Results Demographics satisfaction All patients returned to their previous professional or sporting activities. All patients reported either satisfied with outcome or very satisfied. There were thirteen males and six female with an average age of 45.2 The average follow-up examination post-operatively was 24.4 months

20. Results Clinical outcomes The mean VISA-A score was 92 (range, 66 to 100 points).

21. Results VAS complications Average pre-operative score 5.5 Average post-operative score 0.9 Paired student t-test P < 0.01 Complications occurred in two patients (11%). One patient obtained an stitch abscess that resolved with local wound care. One patient had a re-rupture eight weeks post-operative after falling at a carwash. This was re-repaired the mini-open technique.

22. Discussion Incidence of Achilles tendon ruptures 18 in 100,000 per year and are believed to be increasing in incidence6. At this time, debate still exists over the best treatment for this condition in regards to non-operative care, mini-open repair,percutaneous repair, and open repair of the tendon rupture7.

23. Discussion Our series using the mini-open technique has allowed for minimal complications with a high clinical outcome. We did not experience any incidence of sural nerve injury although this has been reported in the literature with both mini-open and percutaneous repair2, 8-10

24. Discussion strengths weaknesses Validated clinical outcome measurement scale (VISA-A) Standardized procedure Small sample size No pre-operative measurement other than VAS Assessor Bias

25. Discussion Although we add to the body of evidence that the mini-open repair technique is effective and safe for Achilles tendon ruptures, more study is needed We believe the benefits to the patient of lower morbidity, minimal minor complications, and high satisfaction are the strengths of this procedure.

26. References Willits K et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. JBJS AM. 2010 Dec 1;92(17):2767-75. Epub 2010 Oct 29 Calder JDF, Saxby TS Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med 2005;39:857–859. Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P Limited Open Repair of Achilles Tendon Ruptures : A Technique with a New Instrument and Findings of a Prospective Multicenter Study. J. Bone Joint Surg. Am. 84:161-170, 2002. Calder JDF, Saxby T.S. Independent Evaluation of a Recently Described Achilles Tendon Repair Technique. Foot Ankle Int. 27(2):93-6 Robinson JM et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35:335–341 Costa M.L., Macmillan K., Halliday D., Chester R., Shepstone L., Robinson A.H.N., Donell S.T. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendoAchillis. J Bone Joint Surg [Br] 2006;88-B:69-77. Chiodo C, Wilson M Current Concepts Review: Acute Ruptures of the Achilles Tendon. Foot Ankle Int. 27(4):305-13 Ma GWC, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon. A new technique. ClinOrthop 1977;128:247–55. Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21(6):475–7. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon – a prospective randomised controlled study. Foot Ankle Int 2001;22(7):559–68. Parekh SG et al. Epidemiology and outcomes of Achilles tendon ruptures in the National Football League. Foot Ankle Spec 2009 Dec;2(6):283-6. Epub 2009 Oct 13.

27. Thank You