Dear,

the procedure is very frequent in Slovenia. The main problem is the possibility for sural nerve intrapment by the suture and the determination of the length of the tendon. The advantage is the high healing rate and nearly no skin problems.

Regards, Rihard Trebse

Thank you for you contribution Rihard Trebse.

What recomendations do you give to your patients?

Do you put them any special boot like "Cam Walker" in equinus?

Do you think that the patient´s recovery, specialy in athletes, could be better (for example in terms of return to play)?

Best regards

Visualisation of the sural nerve by careful dissection during minimally invasive Achilles repair.

Carmont et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011 3:28 doi:10.1186/1758-2555-3-28

Dear Gustavo

I have a few cases with the percutaneous technique but had complications in two cases (impairment of sural nerve ).

I prefer the traditional approach, since some times the tendon is degenerated and may need to make a tendon transposition (use the peroneus brevis)

In the literature there is evidence that the percutaneous repair of the Achilles tendon is a simple, easy and reliable technique. It seems to fulfil the required conditions: bringing closer tendon ends, maintenance of strong contact, preservation of all anatomical and histological factors inducing healing and a rapid return to social and working activities.

Dear Nelson, Thanks for telling us your experience with this procedure . Which criteria do you usually use to apply this technique? Do you consider it in an athlete???

Dear Gustavo

This technique minimally invasive is very good for athletes because it allows less soft tissue damage, faster healing and early return to sporting activities

I prefer the open technique, to adress the appropriate tendon length and eventual degenerative changes, particularly in ruptures after minor trauma

To supplement the clinical knowledge shared here, about 3 years ago I performed a biomechanical laboratory study on percutaneous repair vs. open Krakow knot technique.

We used cadaver legs and performed the repairs with the skin and soft tissues intact to simulate a clinical setting. Then we stripped the skin off to examine the quality of the repairs and did mechanical testing to failure.

What was interesting is that when the sutures are placed correctly, the percutaneous repair is stronger than the open Krakow (stronger as higher force to failure, higher work to failure combined). HOWEVER, when the sutures are not placed correctly (though the guides were placed correctly), then the strength of the repair is inferior to an open repair with the Krakow stitch.

This led us to confirm the obvious with data: In skilled hands, percutaneous repair has its advantages. However, if the sutures are placed improperly (perhaps due to lesser skill, nuances in patient anatomy, fatigue even), the strength advantage of a percutaneous repair is grossly negated. This could lead to premature failure of the tendon repair.

Article Biomechanical Comparison of the Achillon (R) Tendon Repair S...

Great work Kenneth Ng!!!!!!Thank´s for you contribution. Very illustrative and clearify demostration of the potential of this technique in skilled experimented surgeons, although the open technique is far from being old-fashioned.

I invite all reading Kenneth Ng and cols article:

Biomechanical Comparison of the Achillon® Tendon Repair System

and the Krackow Locking Loop Technique

Keep contributing with your expertise ; )

Percutaneous repair of the achilles tendon works in skilled hands but even in those hands, i.e. the Heidelberg surgeons who "reinvented" percutaneous repair it resultet in sural nerve lesion, something that hardly ever happens in open surgery. We performed an (unpuplished) prospective study in 145 patient, 21 of those with percutaneous repair, which exmined the ultraousnd patterns of healing and p.op. adhesionformation up to 7 yeras pop. There was no significant difference between gliding performance, geometric deformationm or ultrasound pattern between open and closed repair. My personal favourite for acutely injured adults, who are able to wal their crutches savely, is open Achiiles tendon repair on an outpatient basis under local anaesthesia, using the lateral trap suture technique. This technique is by far the strongest between 4 standard techniques, as tested under biomech lab conditions in rabbit tendons.

I have experience with suturing percutaneous Achilles tendon. since 1993 exclusively use percutaneous method and I have not had any recurrence of the tendon healed per Immobilization receive four weeks in plantar flexion, four weeks at a right angle without support and then another four weeks with the support of the leg

Dear Michael Scherer, thank you for your contribution.

It´s great to know that was no significant differences between 2 techniques.

Did you find hypoesthesia along lateral foot in any of those 21 patients?

Do you think that an open Achilles tendon repair with local anesthesia could shorten the recovery?

http://www.vumedi.com/video/a-modified-finger-trap-suture-technique-2/

Percutaneous Achilles Repair - Paul Kupcha (VIDEO)

http://www.vumedi.com/video/percutaneous-achilles-repair/

Dear Gustavo

I have about 10 yers experience in the treatment of Achilles tendon rupture by percutaneous suture . This technique gave me great satisfaction . I received healing in all cases. We applied this technique in cases older than 7 days and got healing in all cases. I did a study on a number of cases to five years away from treatment. We performed ultrasound and MRI examination . Both examinations showed complete healing of the tendon in all cases. The degree of patient satisfaction was greatest . From our observations we believe that Achilles tendon sheath has a major role in tendon healing . Keeping them integrate percutaneous suture technique is a major factor in healing. In cases operated by us we had only one case of temporary disturbances of sensitivity nevus sural path . These disorders were resolved in less than a few weeks. I think this complication depends on knowledge of anatomy and sural nerve suture technique used .

DR . DANUT TARNITA

UMF Craiova Romania

Dear All:

We have a very good experience with percutaneous suture of the acute tear of Achilles tendon/ We use 6 very small incision medial and lateral to the Achilles tendon. Lateral we search the sural nerve to avoid nerve damage ( vessel loop). We perform hand free suture with ethibond 5. (figure of 8 type). Walking boot in equinus for 2 weeks and every week we remove one wedge (4).

No retear, good patient satisfaction. I have only one nerve damage

Enjoy

Dear Ezequiel Palmanovich and Danut Tarnita!!!Thank you for sharing with us your great experience with this technique and your good results...

I invite any of you sharing with us a video with the major tricks of your procedure; )

Kindly see the full text of the technique at:

https://www.researchgate.net/publication/6872681_Repair_of_acute_Achilles_tendon_rupture_using_a_double-ended_needle

Article Repair of Acute Achilles Tendon Rupture Using a Double-Ended Needle

Dear Gustavo

For many years I have practiced percutaneous repair of Achilles tendon with heavy ethibond through small stab incisions, followed by protection with a plaster in equinus for the initial patients or later aircast with wedge insole for three weeks and in neutral for another three. We never had any re-rupture but as the technique was spread to more than one surgeon the main problem arising was nerve entrapmement. With further education this was minimised and patient were satisfied. In my hands there was no nerve entrapment (maybe lucky) but in the series this was risen to was up to 10%

I'm a biomedical engineer, not a medic, but I can share my experience as a patient. I had percutaneous achilles tendon repair (with local anaesthetic) in the mid-1980s. Following the last cast removal, physiotherapy was very difficult due to what would seem to have been (from the comments above) nerve entrapment or adhesion. I could barely move my foot without excruciating pain - appearing to come from the mid-sole area of my foot. Then, after several weeks of trying to weight-bear, there was a sudden release and the pain disappeared. Thirty years later, I go for a run three times per week!

Thankyou Brian for giving us your personal experience as a patient...

It is the most important vision of a procedure that try to be minimally invasive, but it is not exent of complications such as the one you have experienced in your own skin...

I´m really glad that you are fully recovered and take sports activities without any problem!!!