Ultrasound-guided minimally invasive surgery for achilles tendon rupture: preliminary results

Current treatment concepts for Achilles tendon rupture

Achilles tendon rupture is a common and primary cause of lower limb tendon injury suffered during sports-related activities. The causes of Achilles tendon rupture include the calf muscle and tendon overuse, poor tendon quality, and various medical conditions. Historically, acute Achilles tendon rupture was treated conservatively. However, historical techniques are now associated with an increased risk of rerupture. To address this problem, open repair has been proposed. Open repair is associated with a reduced risk of rerupture; however, it is also closely associated with wound complications, like wound infection, whose treatment is time-consuming and costly. Therefore, minimally invasive Achilles tendon repair has been proposed as a promising option with acceptable functional outcomes. Nevertheless, despite its benefits, minimally invasive Achilles tendon repair is associated with increased risks of sural nerve injury and rerupture. In this review, we evaluate the currently used treatment strategies for acute Achilles tendon rupture and their historical evolution to provide evidence-based recommendations for physicians.

Application of Preoperative Ultrasonography in the Percutaneous Minimally Invasive Repair of Acute Closed Achilles Tendon Rupture

Percutaneous minimally invasive surgery involving Achilles tendon (AT) repair has the advantages of a low rerupture rate and fewer postoperative complications. However, due to the inability to operate under direct vision, the injury of the small saphenous vein (SSV) and sural nerve (SN) remains largely a high risk involving many challenges. We propose to introduce the preoperative application and advantages of ultrasonography in percutaneous minimally invasive surgery for acute AT rupture. Our results indicated that ultrasonography could locate the position of the SN more accurately and reduce the risk of iatrogenic nerve injury. Compared with the traditional surface markers, the preoperative localization and marking of AT, SSV, and SN in ultrasonography significantly reduced the risk of intraoperative accidental injury to blood vessels and nerves, which could reduce postoperative complications and promote early rehabilitation of patients. We ultimately exploit the properties of ultrasonography in percutaneous minimally invasive surgery to treat Achilles tendon rupture.

Ultrasonography-Guided Minimally Invasive Surgery for Achilles Sleeve Avulsions

BACKGROUND

Achilles sleeve avulsion, a relatively rare disorder, is characterized by sleeve-shaped injury extending from the calcaneus, located near the tendon insertion site. Unlike midsubstance tears of the Achilles tendon, end-to-end repair is difficult because less soft tissue is preserved distally. Open repair with transosseous sutures or suture anchors is currently favored. The purpose of this study was to evaluate the technical feasibility and functional outcomes of ultrasonography-guided Achilles sleeve avulsion repair.

METHODS

From November 2009 to April 2018, 21 patients with Achilles sleeve avulsions (mean age, 57.8 years; range, 25-82 years) who underwent repair by the same surgeon were retrospectively reviewed. The repair was achieved through a stab wound under ultrasonographic guidance. Two parallel Bunnell-type sutures were crossed over the proximal stump and tied with sutures from suture anchors fixed in the calcaneal tuberosity.

RESULTS

The mean operative time was 44 minutes, and the mean wound size was 1.5 cm. The patients were allowed to walk freely on postoperative week 6 with using high-ankle shoes. At postoperative 2 years' follow-up, the American Orthopaedic Foot & Ankle Society score significantly improved from 70.9 to 97.1 (P < .05); similarly, their 12-item Short Form Health Survey scores improved significantly (P < .05). Only 2 patients had superficial wound infections, which resolved with wound care and oral antibiotics.

CONCLUSION

Our ultrasonography-guided surgical technique for Achilles sleeve avulsions provided excellent soft tissue visualization and availability as well as minimized the wound length to achieve good postsurgical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

High-Frequency Ultrasonic Forceps for the In Vivo Detection of Cancer During Breast-Conserving Surgery

A major aim in the surgical management of soft tissue cancers is to detect and remove all cancerous tissues while ensuring noncancerous tissue remains intact. Breast-conserving surgery provides a prime illustration of this aim, since remaining cancer in breast margins results in multiple surgeries, while removal of too much unaffected tissue often has undesirable cosmetic effects. Similarly, resection of benign lymph nodes during sentinel lymph node biopsy can cause deleterious health outcomes. The objective of this study was to create an intraoperative, in vivo device to address these challenges. Instant diagnostic information generated by this device could allow surgeons to precisely and completely remove all malignant tissue during the first surgery. Surgical forceps based on Martin forceps were instrumented at the tips with high-frequency ultrasonic transducers composed of polyvinylidene difluoride, a thickness-sensing rotary potentiometer at the base, and a spring to provide the appropriate restoring force. Transducer wires within the forceps were connected to an external high-frequency pulser-receiver, activating the forceps' transmitting transducer at 50 MHz and amplifying through-transmission signals from the receiving transducer. The forceps were tested with tissue-mimicking agarose phantoms embedded with 58–550 μm polyethylene microspheres to simulate various stages of cancer progression and to provide a range of measurement values. Results were compared with measurements from standard 50 MHz immersion transducers. The results showed that the forceps displayed similar sensitivity for attenuation and increased accuracy for wave speed. The forceps could also be extended to endoscopes and laparoscopes.

Ultrasound-Guided Minimally Invasive Surgical Resection of Retrocalcaneal Bursitis: A Preliminary Comparison With Traditional Open Surgery

Posterior heel pain is a common complaint that is often caused by overuse injuries. In such cases, the retrocalcaneal bursa is compressed and chafed repeatedly, leading to local inflammation. Sonography is a popular imaging tool used to study the pathology of soft tissues, and it can be used to assist in diagnosing bursitis because of its accuracy. Herein, we report an innovative method to treat retrocalcaneal bursitis under ultrasound guidance. Ten patients with posterior heel pain for >6 months who failed conservative treatment received this ultrasound-guided minimally invasive surgery. An endoscopic puncher and burr were inserted under ultrasound guidance via a stabbing wound, and the swollen retrocalcaneal bursa and bony prominence were resected. The patients were able to ambulate and undergo a rehabilitation program 2 weeks postoperatively. In the patients who underwent this ultrasound-guided minimally invasive surgery, both the average surgical time and average hospital stay were shorter than in those (n = 12) who underwent open surgery. In outcome rating assessment, the American Orthopaedic Foot & Ankle Society (AOFAS) pain score and total AOFAS ankle-hindfoot score were improved in the ultrasound-guided minimally invasive surgery group compared to the open surgery group at 2 months postoperatively. Other advantages included lesser wound pain, shorter hospital stay, faster recovery time, and minimal blood loss. Accordingly, ultrasound-guided surgery appears to be a good option for the treatment of retrocalcaneal bursitis.

High resolution real time ultrasonography of the sural nerve after percutaneous repair of the Achilles tendon

BACKGROUND

Percutaneous Achilles tendon repair has been developed to minimise soft tissue complications following treatment of tendon ruptures. However, there are concerns because of the risk of sural nerve injury. Few studies have investigated the relationship between the Achilles tendon, the sural nerve and its several anatomical course variants.

METHODS

We studied 7 cadaveric limbs (7 Achilles tendons) in which a percutaneous repair of the Achilles tendon was performed. On each tendon, high resolution real time ultrasonography examination was performed by an experienced musculoskeletal radiologist before and after the procedure, with the surgeons blind to the results of the scan both before and after surgery.

RESULTS

In two instances, high resolution real time ultrasonography examination revealed nerve entrapment at the level of most proximal lateral suture.

CONCLUSIONS

Since the sural nerve can be easily visualised using high-frequency high resolution real time ultrasonography, intraoperative ultrasound can be of assistance during percutaneous repair of Achilles tendon rupture.

CLINICAL RELEVANCE

The sural nerve can be readily visualised by high-frequency high resolution real time ultrasonography probes. It could be beneficial to use high resolution real time ultrasonography intraoperatively or perioperatively to minimise the risks of sural nerve injury when undertaking percutaneous repair of Achilles tendon tears.

Subcutaneous Achilles tendon rupture: A comparison between open technique and mini-invasive tenorrhaphy with Achillon® suture system

BACKGROUND

Surgical management of Achilles tendon rupture is still controversial: open techniques have a higher rate of soft tissue complications but a lower incidence of re-rupture than percutaneous tenorrhaphies. The aim of our retrospective study was to analyze and compare clinical and functional results in patients treated with either the conventional open or minimally invasive suture treatment with the Achillon^® system.

METHODS

A retrospective review of 140 patients was performed; 72 were treated with open tenorrhaphy, 68 with the minimally invasive Achillon^® suture system.

RESULTS

With a comparable re-rupture rate, there was a statistically significant reduction in surgical time, incidence of minor complications, time required to return to sport activities and return to work in the minimally invasive group.

CONCLUSIONS

Achillon^® mini-invasive suture system is a reliable tool for the Achilles tendon ruptures, able to reduce the incidence of soft tissues complications if compared to the classic open tenorrhaphy, while maintaining strength of the suture and leading to superimposed functional outcomes.

Intraoperative ultrasound assistance for percutaneous repair of the acute Achilles tendon rupture

Various methods have been used to treat the acute Achilles tendon rupture. Traditional open repair is associated with a higher rate of complications. Percutaneous methods avoid most of the disadvantages of open surgical treatment, but the degree of tendon regeneration cannot be ensured. The authors prospectively followed 40 patients with acute Achilles tendon rupture who underwent percutaneous repair with intraoperative ultrasound assistance an average of 13 months after the injury. No surgery-related complications, such as wounds or deep infections, sural nerve injury, or re-rupture, were detected at follow-up. This technique avoids injury to the sural nerve, minimizes wound complications, and provides a strong repair.