Foot & Ankle International - July 2016 - (Page 794)

653373 FAIXXX10.1177/1071100716653373Foot & Ankle InternationalMcWilliam and Mackay research-article2016 Surgical Strategies The Internal Brace for Midsubstance Achilles Ruptures Foot & Ankle International® 2016, Vol. 37(7) 794-800 © The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100716653373 fai.sagepub.com James R. McWilliam, MD1,2, and Gordon Mackay, BSc, MD, FRCS(Orth), FFSEM(UK)3,4 Abstract The efficient and effective function of the Achilles tendon is essential for normal gait and sporting performance. The optimal technique for the operative repair of the Achilles midsubstance rupture remains controversial. Suboptimal outcomes are common even after successful Achilles repair. Factors contributing to poor outcomes include a tenuous soft tissue envelope (leading to wound complications, peritendinous adhesions, and poor tendon healing,) as well as failure to maintain appropriate musculotendinous length, even after successful repair. We present a new technique using the InternalBrace (IB) and a modification of the Percutaneous Achilles Repair System (PARS; Arthrex Inc, Naples, FL), the Achilles Mid-Substance Speed Bridge Repair. This IB approach is knotless, respects the soft tissue envelope, and allows the appropriate musculotendinous length to be set intraoperatively. The IB principle enables direct fixation to bone allowing early mobilization while minimizing the risk of knot slippage, accelerating recovery, and allowing for restoration of normal function. Level of Evidence: Level V, expert opinion. Keywords: Achilles tendon repair, midsubstance rupture, InternalBrace, knotless Introduction Traditionally, Achilles tendon ruptures in healthy active individuals have been treated with direct suture repair via an open incision. Outcomes after operative treatment are enhanced by early weightbearing and functional rehabilitation.2,9,10,14,18,22,23 Recent studies, however, have demonstrated comparable results with early functional rehabilitation between operative and nonoperative treatment of Achilles ruptures.21,22,28,29 Although these results may be comparable, there is concern that, especially in the elite athlete, functional deficits after Achilles injury lead to significantly decreased performance.1,12,13,17,24 We believe nonoperative treatment of rupture of the Achilles tendon invariably leads to lengthening of the musculotendinous unit. Such lengthening can weaken the force delivered by the musculotendinous unit by decreasing the resting sarcomere tension in the muscle (as demonstrated in the Blix curve), as well as increasing the effective excursion necessary for the musculotendinous unit to deliver force. Empirically, one might posit that restoring appropriate musculotendinous length by operative repair would lead to a superior functional recovery. Based upon multiple studies, however, this is not invariably the case, and weakness after repair of Achilles ruptures persists.15,20 Although the clinical results would speak otherwise, we believe it is counterintuitive that rupture of the thickest and strongest tendon in the body is best treated conservatively, and that a lengthened musculotendinous unit is the best outcome that can be hoped for. We believe that rather than indict the Achilles tendon rupture as inherently and inevitably leading to such musculotendinous lengthening and its attendant disability, it is worthwhile to investigate current repair and rehabilitation techniques, with hopes of finding room for improvement. As an alternative to traditional open Achilles repair, we present the Achilles MidSubstance Speed Bridge repair, a modified percutaneous technique that combines the benefits of percutaneous repair with direct bone fixation, bypassing the rupture site as well as compromised tissue proximal and distal to the rupture site. By minimizing disruption of the soft tissue, minimizing suture slippage through the tendon proximally, and fixing directly into bone distally, the Achilles MidSubstance Speed Bridge repair may mitigate some of those factors that can lead to persistent weakness after Achilles tendon ruptures. 1 New York Medical College, Valhalla, NY, USA Specialty Orthopaedics, PLLC, Harrison, NY, USA 3 University of Stirling, Scotland, United Kingdom 4 The MacKay Clinic, Ltd., Scotland, United Kingdom 2 Corresponding Author: James R. McWilliam, MD, Specialty Orthopaedics, PLLC, 600 Mamaroneck Avenue, Suite 101, Harrison, NY 10528, USA. Email: mcwilliam@footandankle.md http://www.sagepub.com/journalsPermissions.nav http://fai.sagepub.com

Table of Contents for the Digital Edition of Foot & Ankle International - July 2016

TOC/TOC/Verso
Editorial Board
Advertiser Index
Long Term Follow-up of a Randomized Controlled Trial Comparing Scarf to Chevron Osteotomy in Hallux Valgus Correction
Clinical Outcome and Fusion Rate following Simultaneous Subtalar Fusion and Total Ankle Arthoplasty
Anterior Heterotopic Ossification at the Talar Neck After Total Ankle Arthroplasty
Secondary Arthrodesis After Total Ankle Arthroplasty
Functional Outcomes Following First Metatarsophalangeal Arthrodesis
Increased Reduction Clamp Force Associated With Syndesmotic Overcompression
Pain Threshold Tests in Patients With Heel Pain Syndrome
Long-term Results of Chronic Achilles Tendon Ruptures With V-Y Tendon Plasty and Fascia Turndown
Peroneal Tendon Abnormalities on Routine Magnetic Resonance Imaging of the Foot and Ankle
Incisura Morphology as a Risk Factor for Syndesmotic Malreduction
Total Arthroplasty of the Metatarsophalangeal Joint of the Hallux
Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy
Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act
Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia
Gastrocnemius Proximal Release in the Treatment of Mechanical Metatarsalgia: A Prospective Study of 78 Cases.
Response to "Letter Regarding: Gastrocnemius Proximal Release in the Treatment of Mechanical Metatarsalgia"
The Internal Brace for Midsubstance Achilles Ruptures
The Evolution of Patient Safety
Education Calendar
Foot & Ankle International - July 2016

Foot & Ankle International - July 2016