Midsubstance repair is an alternative technique to treat Achilles tendon ruptures

 The minimally invasive midsubstance surgical technique for acute midsubstance Achilles tendon ruptures passes sutures longitudinally through the distal Achilles stump and anchors proximal sutures into the calcaneus for early range of motion and weight-bearing.The midsubstance SpeedBridge (Arthrex) technique may be particularly helpful for distal Achilles tears when a limited amount of the patient’s tendon is available.

Distal anchor preparation

If fixation of the proximal Achilles tendon sutures to bone is desired, the midsubstance construct can be used instead of distal Achilles tendon percutaneous suture passing. Two longitudinal incisions are made along the posterior aspect of the heel at the peripheral insertion of the Achilles tendon distal to the maximal convexity. Incisions are spaced along the sides of the Achilles tendon insertion. A 3.5-mm drill and drill guide are used through each incision and placed flush against bone (Figure 1). The drill is inserted into bone and oriented slightly convergent towards midline and slightly plantar. Each drill hole widened using a tap.

A rigid suture passer with inner Nitinol wire is passed longitudinally through the center of the distal Achilles tendon stump using controlled, continuous pressure. The surgeon’s dominant thumb guides the sharp tip of the passer through tendon. The passer is brought out through the proximal incision to retrieve one pair of proximal sutures. During suture passing, the Nitinol wire is drawn back to the tip of the passer. Then, the entire device is removed from the distal incision. Trying to pass the sutures only through the inner Nitinol wire can result in suture tangling and increased resistance.

Achilles tensioning, anchor insertion

The ankle is plantar flexed to tension the Achilles so that end-to-end proximal and distal tendon apposition is achieved. An assistant holds tension on the opposite pair of sutures to ensure that Achilles tension does not change prior to anchor insertion. The rupture site should be palpated to confirm that no residual gap or excessive overlap of the tendon ends is present. Sutures are passed through the eyelet of the 4.75-mm anchor, which is gently malleted into the calcaneal drill hole and hand tightened until the anchor is flush with or slightly buried in the bone.

vedio link: https://studio.youtube.com/video/yqNkS2l56sg/edit

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