AANA Lab Course 908-Foot and Ankle Arthroscopy (APEx)-Minimally Invasive Repair_ The New Norm_ Good Results_Fewer Complications-Phinit Phisitkul, M.D.

Minimally Invasive Repair_ The New Norm_ Good Results_Fewer Complications-Phinit Phisitkul, M.D.

Pdf Summary

The presentation by Dr. Phinit Phisitkul reviews minimally invasive surgical (MIS) techniques for acute Achilles tendon ruptures, highlighting their advantages and limitations compared to traditional open repair and non-surgical treatments.<br /><br />Conventional open Achilles tendon repairs offer good outcomes but are associated with high wound complication rates (up to 34.1%) such as infections and adhesions. Meta-analyses show surgical repair provides superior peak muscle torque and better functional and pain scores compared to non-surgical treatment.<br /><br />Minimally invasive repair techniques—including percutaneous suturing (Ma-Griffith, Maffulli), use of customized jigs (Achillon, PARS, Dresden), and endoscopic-assisted repairs—combine benefits of surgery and less invasive approaches. Evidence from multiple randomized controlled trials involving over 700 patients demonstrates that MIS approaches have comparable clinical and functional outcomes to open repair, with reduced superficial wound infections, quicker return to work, and shorter hospital stays. However, MIS methods may carry a higher risk of neurological complications, particularly sural nerve injury. The risk varies with limb positioning during surgery, with external rotation minimizing nerve injury risk.<br /><br />Various MIS techniques are described, such as the Dresden and Achillon methods, limited-open repairs using modified ring forceps, and percutaneous knotless suturing. Costs of implants vary considerably. Endoscopic control aids in minimizing soft tissue damage and protecting the sural nerve.<br /><br />Biomechanical studies highlight that cyclic loading post-repair can lead to gap formation in the tendon, underscoring the importance of robust suture techniques (often using 4-6 strands of nonabsorbable sutures).<br /><br />Dr. Phisitkul’s personal series of 23 patients treated with MIS Achilles repair showed significant improvements in pain and function, fast return to sport (~5.7 months), and minimal complications (one superficial infection, no nerve injuries or reruptures).<br /><br />In summary, MIS Achilles tendon repair attempts to preserve tendon biology, reduce wound complications, and improve patient satisfaction. However, careful surgical technique is vital to avoiding sural nerve injury and tendon lengthening. These modern approaches offer promising alternatives to traditional open surgery for acute Achilles ruptures.

Keywords

Minimally Invasive Surgery

Achilles Tendon Rupture

Percutaneous Suturing

Endoscopic-Assisted Repair

Sural Nerve Injury

Wound Complications

Functional Outcomes

Biomechanical Studies

Achillon Technique

Return to Sport