Loading summary
Transcript43 lines
- [00:01]
A
Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members.
- [00:27]
B
This is Joe Park Today on a special episode of the AOFAS Ortho Podcast. I'm here with my co host, Brett Smith, and we have two recurring guests on our show who have really, I think, changed the landscape of foot and ankle orthopedics. And we have Bob Anderson from Charlotte, North Carolina, as well as Marty o' Malley from New York at the Hospital for Special Surgery. So thank you guys for joining us. And today our topic is percutaneous versus open Achilles repair. And so this is a topic that's really important for all orthopedic surgeons, but specifically for people like Brett and I who do foot and ankle and try to take care of athletes in the same way that Bob and Marty have done for so many years. And if you guys are okay starting out, I was hoping this could just be a sort of an honest and informal discussion about what you guys have seen over the years and how the athletes have responded to either technique. And thank you so much for joining us tonight.
- [01:26]
C
Pleasure.
- [01:27]
A
Pleasure. Absolutely. So I started, like, mid-90s, and one of my common things they did in the office was debride ethibones from the back of people's Achilles tendons. Who? Patients who had their Achilles tendon, because Russ Warren taught everyone to use a number five Ethibon on an Achilles repair. And they have these giant knots, and then they'd send them to me and, like, the patients come every week, and I would chip away at the Ethibon, like, layer by layer until I finally got the Ethibond out, and then I could close the wound. Right. So the open technique for many years was problematic. I changed it a little bit. My technique using smaller sutures, trying to, you know, cover the peritina and stuff. But I kept hearing about Bob and this percutaneous technique. And then I went on a quest. I said, all right, for six months, I'm doing every one of them. I'm doing a percutaneous technique now. You know, you have to know that Jonathan deland was one of the inventors of the pars. He saw the kill on, and then him and Tim Charles and all these guys got together. They learned how to pass a locking suture and went from the kill on to the pars technique, the original parse technique. So I was in the midst of this whole discussion of how to pass the sutures and all this stuff. And so I did it for six months, and I will be the first to admit I am not a good parsurgeon. So I would say the half the time when I finished, it just didn't feel that good, or I felt like it was bunched up too much. My knots were not in a good spot, or I didn't get the locking the right way. And so half the time, I would always make my pars, not transversely, longitudinally, because I planned on reopening. Now, maybe I was just doing myself the whole time I was preparing for failure, but if I felt a little gap or something, I would just open it up and I would look at my sutures. And I really didn't like how I did it. My first one I ever did, first I ever did, I told the guy, you know, Mike, I got a sural nerve. He didn't care because I told him. He. He insisted I do a pars technique. And I said, well, you know, I haven't done many of them. I've never actually done one in a human being. And I did it. He got a sural nerve, like, when it finally came back. But I definitely tweaked his sural nerve. So I went and did the pars. And then I had one episode where I had a guy who was 28, or I did a pars who was 8 months post op, and he had open re rupture. So it was basically he was jogging on the beach or just light jogging eight months. And it was like someone took an ax wound to the back of his leg. The big open re rupture that called me from Southampton Hospital. I'm like, I had never seen that. And so of all the complications I'd seen with the primary Achilles repair, this was the worst one I've ever seen. And I said, done. Not doing it anymore. And so I went back to the open technique, and that's how I became. They went from the pars back to the open. And I've been at the open for the past. I think that was two, 10 years. And I'm pretty happy with my open technique. And so that. That is. That was my thing. My concern with the pars was that maybe I wasn't doing right, that the sutures are under the skin and people are getting this kind of soft tissue reaction to the fiber wire. I don't know if it was a problem with the pars or the fiber wire or what they're Getting a soft tissue react. And mine didn't look as good as when I did an open technique. I could actually kind of make the tendon a little more narrow and make it more like an Achilles tendon. And I felt like I couldn't make it cosmetically as good. It looked like a tendon like the open. So that's why I'm an open Achilles tendon surgeon, Bob.
- [04:56]
C
Understandably so. No. So I go back just a few more years earlier than Marty and you know, I was taught on how to do Achilles tendon rupture repairs. Open, fairly extensile longitudinal incisions. The big number five Ethibon that Marty's talking about, that's what I was trained on. And you know, I think we got pretty good at it. My concern about the open approaches was just wound healing issues and infection. And we had some. One of my partners had a very well known athlete who unfortunately ended up getting pretty bad infection to the point where everything had to be cleaned out. It was somewhat of a disaster and ended up getting a free tissue transfer is just one nightmare after the other. So this is back in early 90s and no doubt our surgical techniques have improved, our incisions have gotten smaller even with the open techniques. But I had the opportunity to go over to Switzerland and this was about late 90s, and I had the opportunity to meet Dr. Assault. And he was basically the creator of the alkalon that Dr. O' Malley's talk about, which was. It was a jig. It was a plastic jig. You know, you have to remember that the Ma&Griffith type of percutaneous repair techniques have been around since the 70s. And this very clever orthopedic surgeon came up with an idea of having a plastic jig that could minimize the incision. And I was pretty intrigued. I got opportunity to watch him in the operating room and came back and tried many of these Aqualon devices and thought it was pretty good. But I wasn't very happy with the fixation. I wasn't very happy with trying to get into large calves. And so I went to one of the companies and said, listen, I think we can improve upon this idea of minimally invasive repairs utilizing an improved jig configuration. And so we brought a few other people into it, including Dr. Deland, as Marty just mentioned. And so basically three of us went down and over a period of about a year we developed the parse technique. And this was 2010 by the time we got it out. And you know, it did it have. It's a leap of faith because you can't see the sutures where they are, you can't see the tendon where it may or may not be. And so there is a learning curve to it. I must say that, you know, Marty is absolutely right. We, you know, initially when we did them, we had a little bit of an issue with, you know, the sutures itself. And over time, the sutures got better, they got softer, less knot stack, better techniques on how to hide the knot. And I got to the point where I probably had not open an Achilles, an acute Achilles tendon rupture in the mid substance region for the last, I guess 15 years. I just started doing it and I think I got pretty good at it just by doing it over and over again. And I like the idea, I'm not saying the PARS outcomes are any better than open, but I do like the idea that I believe the complication rate is less in regard to wound healing and infection. The downside, there's been some good articles. 2014, there's an article again comparing the two and showing back then that yes, wound complications, infections lower with percutaneous, but the surro nerve issues like Marty was talking about is a little bit higher with the percutaneous. So again, it's been a technique that I enjoyed doing. I think like any Achilles tendon rupture, you're going to have some great results. You're going to have a couple that are going to fall through the cracks and unfortunately not heal the way you'd like them to. But again, I think it's, it's an option to consider, particularly trying to reduce the wound healing issues.
- [08:21]
A
For me, I think that the data, like your study with Andrew in 2015, didn't show a difference in wound healing. Correct. Actually did slightly worse with open, right?
- [08:34]
C
Yes, slightly worse open. The trend was people who had the percutaneous, or I should say mini open. It's not true percutaneous, but mini open got back a little bit quicker to their activities. And the wound issue issues were trending towards less training.
- [08:47]
A
Towards less.
- [08:48]
C
Yes.
- [08:48]
A
Since that time, there's been multiple studies that have shown no difference in open versus percutaneous. Now, a lot of those studies that are of Europe and they're not using the pars, they're doing like a Dresden technique. So the Dresden technique is basically taking a curved curette up both sides of the tendon and kind of passing. It's kind of like a. You're taking a curved. Correct. With a loop. You pass the suture through and you pull it down that way. And there's this whole technique of locking it and it's really like doing a PARS with like a, just a curette. Right. And so if you compare the real PARS studies towards the, the open technique, there'd be less wound complications and higher sur nerve. The numbers aren't big enough to be statistical significance. If you look at the overall minimally invasive body of work, it seems to be the same. But that's, you know, that's some kind of funky minimally invasive. Lots of different techniques are used in those techniques. So one of the reasons that for me and my big concern is the stretch out. And Clanton wrote an article doing a biochemical analysis of PARS open, all these different techniques, you know, pars versus open, and he found that the open at the first 250 cycles had the lowest amount of gapping. After 250 cycles, they all were the same. So everything kind of gapped a little bit for the first 250 cycles. The pars, the open, they had different open techniques, but that open gave less at the beginning. And so for me, the reason I stick with the open is because I'm worried about that initial stretch out. And I feel like when I do the open, I'm like, I'm doing a lock middle and I'm, I'm like water skiing on that thing. I'm trying to get as much of the creep out of it as possible at every throw and I'm trying to get five lock sutures on both sides. And I feel like that initial creep that Clanton talked about somewhat eliminated. We know that even if you do a, like a Kessler, you know that study out of, with the tantalum beads, they did a crack out and they put a tantalum bead and they put them in a cast even they cast it open like 15 millimeters. So there's some stretch creep in the whole system. But my whole think about the whole thing is how can I make the least creepy. And I think that for most with many open incisions, not giant womps like we used to do in softer sutures and being nice to the sutures, I think the infection rate's about the same as the pars, but I feel that initial creep is less sort of gets me.
- [11:18]
C
That's a good point. And I'm very diligent. I'm very, a little bit, maybe I don't know what the word is, I'm very conservative. When I do my pars where I do the same thing every strand. I would do the Water ski on and I do double lock on both sides of the rupture, particularly in our more active individuals. I think Tom Clanton's study subsequent showed that if you do lock it, it's
- [11:40]
A
a much more way better if you lock it. Absolutely.
- [11:43]
C
It's a much more secure construct. So I do double lock. We made that provision in the pars when we developed it that you didn't have to lock at all or you could lock on one side, or you could double lock on one side and the same for the other side. So I'm sort of very consistent in the way that I do it where I do put the strands and I check them each one individually, make sure I get a little water ski, like say a little water ski tug on it, try to get that initial creep out as much as I can. And I do like the idea of locking. I think locking does help to secure it. And again, my philosophy has been I'm not trying to get a construct where I'm going to walk somebody right away. I'm just trying to get them where I can move them safely in the first 10 to 14 days, do a little plantar flexion movement. And I found that for me, with those limited goals, it's worked well.
- [12:31]
B
So from my perspective, my big question is always the recovery. So I think whatever technique you use, you know, obviously you guys are both expert surgeons and I know that you would never leave the OR without feeling confident in your repair. But you know, with some of the athletes that we have seen have these ruptures repaired and then trying to get them back very fast, you know, four months, six months, either technique. Do you guys feel that there is a technique that kind of can cheat biology, that can sort of make a tendon heal without. My concern is the over stretch, as Marty said, you know, they. Because they don't hurt, they don't have pain and they feel good, but they just can't. Single stance, heel rise, sometimes, ever. And I think that's my fear, you know, doing pretty much any technique for the Achilles.
- [13:21]
C
Oh, it's biology. I mean, the tendon still has to heal. No matter what technique we use, the tendon still has to heal. And you know, I've seen some guys have had great repairs. No matter what you've done, whether it's the mini open or open. And some people just don't lay down good collagen and they've developed cystic changes and unfortunately has not had the best results going forward. But you know, I think where you're going with this Is, you know, like people talk about 10 and attendant versus 10 and a bone. You know, can we get them back quicker if we bypass the distal tendon and just take the proximal tendon stuff and go right to bone? And you know, we've reviewed that with our NFL players trying to figure out which type they've had. And so far to date, no one type of procedure gets somebody back consistently quicker than another. So whether you do open, whether you do mini open tendon to tendon, mini open tendon to bone, they all seem to be in about the same, you know, same range. I don't know. Marty can comment on that.
- [14:15]
A
Yeah, so I think that like, I think it's not realistic to think you're getting back at four or five months.
- [14:22]
D
Yeah.
- [14:22]
A
I think if you look at the rehab protocol from like, if you go on the Internet and look at like Mass General, I mean there's like, you can find almost every orthopedic group has Achilles tendon rehab protocol and it's all over the map. And Bob, years ago and I were talking about it like, we don't want him getting anywhere neutral till eight weeks. Like, we were like, we were like. And there's data now recently from a fuli about slow down rehab after percutaneous repair that's actually did better. So the thought that you're getting back at four months is ridiculous. When I operate an athlete, I tell them at six months I will release you to your team, but that's not mean you're ready to go back and then it's going to take you a couple months to get better. Now how quickly you come back after, that's different. There are some guys at six months look great, but there's no, I don't know of any tenant in the world that's going to be ready for a full load at 4 months. No matter what your technique, because we know it still stretches out, you know, up until like stretch out for five or six months. So you're trying to do. For me, I'm trying to do some, I try and do an open, really strong technique. My rehab is if you're an athlete I see with three days, you start plant flexion exercise, you go in a boot because I have a team around you of people who can monitor you. Right. If you're a regular person, I see you in a week, you go in the boot and you start some therapy. I know I've made it strong enough that you can start doing plantar flexion in a week. And then your touchdown weight Bearing, but you're in the back of head boot with your foot 30 degrees down. You're not really loading your Achilles. I'm just trying to get them to load their leg and maybe the muscles in their leg. And at four weeks they're putting some more weight on. But at six weeks, they're still in a boot and crutches and their foot still kind of pointed down. You can walk on it, but you're not really stretching it out. And in eight weeks, I'll let you get near neutral. That's about as close as you're getting. And a lot of it, if you just focus not on like the range of motion and the stretching. If you just focus on the first eight weeks, just on your plantar flexion strength, I think that's really something we serve like, forget about. I saw three today. I'm like doing so many Achilles that it's like two or three in the office every day. And I saw my first guy stretched out. I'm like, they come in, when I walk in a room, the patient's on their stomach with their feet like this. They know the drill. It's like, assume the position I walk in. They could be in there for 20 minutes on their stomach waiting for me to get there. But they know when they come back, they have to show me their tension. And they have to know that no one pushed them in dorsiflexion until eight weeks. I mean, no one even gets a little hint of Dors reflection. So that's one of the things that, that you just got to work early and think about how you can make the muscle better and how you can work that muscle and wake the muscle. So that's all like the muscle, as soon as the tendons cut, that muscle starts changing physiologically. It's under tension the whole time. So like, you try and put it back together and then you try and work it.
- [17:08]
C
I would agree. I mean, I think, you know, why try to rush them? You know, I always keep telling people, don't let your ego get in the way. Because people say, well, hey, I'm really a great surgeon. I got this guy back at four months or six months or whatever. But as we all know, I mean, the kiss of death is if they over lengthen, if they over lengthen now, their career is done. And I just don't want to take that chance. I try to educate the patient that, listen, you just don't want to have that risk of over lengthening. And this is not, we're not going to rush this Back, we're exactly what Marty said. I like to take my time and, you know, get a moving plantar flexion early, but avoid dorsiflexion. Avoid any passive dorsiflexion till three months. Don't go past neutral, as we said. It's just that, you know, I just, I've seen too many people come in that have been over lengthened and it's just not worth it. I just think it's better to be on the cautious side and go slow.
- [17:55]
A
Yeah, we have those two guys in the NBA, they did three weeks apart. One team just said, you're out for the year, right? The other team said, we don't care when he comes back is for Tatum. They said, we don't care when he comes back. We do not care. We, we assume he's gonna be out for the year, right? For the Pacers. They said they took him out for the year. He goes, oh, it's great. I have to be like, you know, it's just two different ways to look at it. One, one tried to completely take the pressure off the guy and say, okay, you'll be, you'll miss the year. That's fine. He was like, you know, and the other one said he didn't really want to come out for the year, right? So. So he said, okay, fine. But there was no expectation. Like the whole time we weren't going like, you got to be back for this. Got to be back for this. When I saw him two months ago, you know how when they're, you know, you get to five or six months and you're making such good progress and then you're making slower progress. He was at the slower progress stage. He had hit a little bit of a wall. And I'm thinking like, I don't know, maybe he's not coming back, right? We weren't talking about coming back. We're just looking at every week, two week strength increase in how he did. We didn't even talk about coming back the whole time. So if you just tell them, like you're not, like, don't think about sports for six months. A regular person, like, if you're just going to go play some tennis or things like that, I think that's fine. To play some light tennis at six months, it takes these guys nine months and they have someone living with them, working with them all day long. And you just got to protect them from the therapist. Because the therapist is all about motion. Therapies are always focused on. I got their motion back, I got the Motion like, no, we don't want their motion back. We don't want any motion. No one's ever. Bob, have you ever made it one too tight with a primary Achilles repair? No.
- [19:28]
C
So we always. Maximum tension, maximum plantar flexion. Never had one be too tight.
- [19:33]
A
Yeah. So the only time I've ever made it too tight was like. Like a chronic rupture with an FHL where you're, you know, taking the FHL and you're putting in a big biotinius to screw the calcaneus and it doesn't give as much because it's actually a normal tendon. Doesn't really have much creep. But I still have to go back. But it was stiff forever. So those are. The people get a little stiffer like on those. But we tell them, you will eventually stretch out. Let your body stretch it out. You do not need anyone to stretch it out. Like 3 months. No passive dorsiflexion until 3 months. You can walk on it. You'll stretch a little bit as you walk, but no one's pushing on you.
- [20:07]
B
Great.
- [20:07]
A
Now I have a. They come in, they get a slideshow. It's like, like I'm like, I can't even talk now without a PowerPoint. I'm like, I talked to my wife. Let's go through the PowerPoint. I'm like, if you are stretched out at three months, you will not unstretch. That's what I tell them. There's a study. Your Achilles 10 rupture score is at 3 months. Is predictive how you turn to sports a year. So the first three months, like, the guy goes, I hate my boot. I'm like, like, you can. I don't care if you hate your boot or not. Like, you want to do well with this. Just follow the thing. Do not stretch out for the first three months. It's. It's going to stretch itself. That is it. And honestly, I think I like, I sit next door to Andrew Elliott, 100% pars guy. Patients do really well. It's like two guys, we sit four feet away from each other and we do it different. But he spent time and he didn't give up where I gave up. As soon as that guy had the open rupture, I just mentally couldn't do it anymore. But he does the double lock. And I see his techniques and I see his patients post op and we see each other. We see patients on the same day. So sometimes I see his patients post op. It looks good. I think the most important thing is whatever you're comfortable with. And if you don't have a lot of it bats, my. My gut is, if you don't have a lot of it bats with the pars, it's a little hard to do maybe, if you don't have a lot of experience with it. If you're, like, doing one Achilles every three months, might as well make an open incision and make it tighter. If you're doing, like, one or two, one a week, and you're doing, like, 50 a year, and you get, like, a real rhythm with your pars, with your locking sutures and burying the knots and going a certain way, I think that's like, a completely great technique. It's all about setting the tension and not moving too fast. So how you get there. There's lots of ways to get there.
- [21:50]
B
The two questions, Marty, when you do your open approach, and I've asked you this before, but can you describe the way that you make your incision for that, for the open approach?
- [21:59]
A
So it's find the gap, right? Mark out the gap. Where. I know where it is. An MRI or ultrasound or. I usually do it on office ultrasound. Make a medial incision pretty far off the midline. I find the peritoneum. I'm like. I spend a few minutes, like, late dissecting the peritoneum from the skin, which used to be heresy. Like, don't touch that. So I just find that, like, I want to close it afterwards. And then I'll put a zero vicro on either side of the suture, right? And that zero vicro allows me to pull it down and make my incision smaller. But I can get my Keith needle. I do a Keith needle with the number two orthocord. I do a locked band now, and my first one may not be up that high. And then I'll pull it even more. My second will go up higher so I can get five across it. And then I'll tie down the zero vicro and I'll check the tension, like, on the other side. And just so I know where I am, I got to be at least equal to the other side. If I'm looser than those, that I'll never make it with those orthochords. And once you tie down the orthochords or the big sutures, they're hard to untie. No matter, you know, who knows? So then I'll check from the end, make sure there's more plantar flexion, more inversion. I've tightened as far as I can not spur it inside. Then I'll do a little epitanon. 3O suture, vical suture. That's been shown to increase the initial stiffness in the flexor 10 in the hand by like 160% that I've closed the peritina with the 3o vical. Then I use a monoclo and then a skin. I mean the incision most of the time is you know, 4 cm. 3 or 4 cm. Sometimes I'm wrong. Like you get in there, it's like oh, there's something going up the other way, you know, or something. There's something I don't predict. I have to make it a little bigger. But I think the concept of anchoring to your heel is to make it better. Does it bypass like does it bypass the repair? Does it put. No, no stress on the repair. Well that goes for that to heal. Heal. And two I got, besides the person with the infection, I got two guys with heel pain and their calculate lights up like crazy. Like anytime I operate in someone's haglins where it's a bad hagglens with a lot of bone resection, I have to put anchors in the heel. I've been through every single anchor there is in the market. Knotless anchors, the sonic anchors, the four, the double row. Putting anchors in people's heel because they hurt forever. Now most of the time it goes away, but it causes edema. So to, to add one more layer of complication to an Achilles mid substance just doesn't make sense to me. I think. I'm not sure what you're getting from it. Do you kind of agree with that, Bob? Do you think you're getting anything from the speed bridge that except for the
- [24:28]
C
distal ruptures, I prefer to go tendon attendant. Yeah, you know, the studies coming out now show even up to 20, 25% instance of heel pain at one year when you use, you know, anchors or large screws into the calcaneus itself. So I tend to go tendon to tendon and I've always. That's the way we designed the system to be. I think it's good to get that equal tension on both sides rather than bypassing it. But that's always been my preference.
- [24:52]
A
I have 100% instance of heel pain where I anchor the heel. Let's just tell you that I tell people about it before I. I'm so sick of it. And I'm like, all right, we're going to take this off. But if I have to anchor to your heel, it's Going to hurt for a while, you know.
- [25:04]
D
Yeah, I think the whole idea, I mean, we always obviously learn from the past, right? So there's that old study from the military with the Achilles, right. Put them in cast for three months or repair them primary. And we learned, okay, repair them primary. And then there was a whole European studies for, you know, that was probably like the 2000s, where they said, well, you don't have to repair them if their gap is less than an X number of centimeters, blah, blah, blah. But at the end of the day, tend to tendon healing with early weight bearing showed that the reason why they heal so well is that positive stress on the tendon helped to heal them stronger. So we learned that a long time ago and we forgot it and I think we're learning it again. So I agree with you, Dr. Melli, that tendon to tendon component is the way we should look at it.
- [25:53]
C
It is good. I think that, I think too the thing to stress is that you don't want to put people into a cast for two, three months. I mean, you want to go in and start early motion, get that college realigned, get that collagen built up. So that's why I like avoiding tenodesis effects and trying to get my guys moving, you know, in that first 10 to 14 day window with protection, with caution, with good compliance. But yeah, no, I mean, the, you know, we've been able to do that with, with the, the minimally invasive technique. And you know, I started utilizing the transverse incision early on and I always continue that. I did find early on though, when you use a transverse incision, you definitely want to leave your sutures in longer. So I leave my sutures in four weeks to allow me to start early range of motion, not have that concern about wound dehiscence. So I think if you're going to do the PARS technique, you're going to do it through a transverse incision to try to, you know, preserve your peritina. That's fine. But you want to make sure the sutures stay in so you don't get a dehiscence.
- [26:50]
D
That's a good point. I think that's a very good point.
- [26:53]
B
Bob, can I ask you a quick question? I've seen now, you know, I tend to do the open technique and I've seen this sort of variant where when the Achilles ruptures, the most posterior fibers are very long. Like they're kind of these long stringy fibers. And it seems in my experience, almost like they're coming close to the Myotendinous junction. And so if, when I'm opening, I'm often like, Marty, like, pulling it down and trying to get into good tendon. And my question is, like, do you feel like sometimes with the pars that it's difficult to tell if you're in good tendon or let's say, muscle or fascia? Like, is it challenging? I know you've done so many, but for those younger surgeons out there, is there a learning curve to know when you're in great tendon?
- [27:37]
C
Well, absolutely. That's why I have to check each strand. So when you put a suture in, you want to pull it and see if it maintains. So the tendency.
- [27:44]
A
Talk us through a pars.
- [27:45]
C
Yeah. So the tendency of the pars. Again, I do a transverse incision at the level of the palpable defect. So mid substance rusher, I do a transverse incision. I find the sural nerve. I, you know, avoid the sural nerve. I take it off to the side. If the peritoneon is not already ruptured with the rupture, then I'll create a transverse, you know, incision in it. And then I now can see the entire Achilles rupture and the peritoneon. And it's important when you use the pars, the jig, the arms of the inner jig have to be within the peritoneon. If they're not, that's how you get the sural nerve irritation. So when you draw those sutures out, they have to be within the confine of the peritoneon to avoid the overlying sural nerves. That's why it's so important to be certain that your inner arms of that jig are inside the peritoneon in their entirety. And then what I'll do is if I think I have a proximal rupture or a rupture that's retracted proximately, I should say I'll go ahead and I'll place a. A stay suture. So I'll use the number one location, one number one needle, and I'll put a stay suture, and then I'll pull it, and I'll pull it down just like what Marty, what you're describing for yours. I'll just pull it down and make sure that I'm not only a good tendon, but it helps me pull that tendon back down to the opening, so to say. And then I can reintroduce the jig and then again, put even more proximally placed sutures. Above it, so you can work your way down like that. Again, I think it's important that you check every strand. Now, what I tend to find people do, and I've done it myself, is that you'll get, for lack of better terms, you get an air ball, you put the jig up there, you pull it out and the suture just comes right with the jig. Like you didn't get anything. You go like, oh, my goodness, what happened? What I found is you typically, you're too deep as you go proximal. That Achilles tendon gets very thin and it's very superficial. It's right underneath the skin. So I tend to find people end up being below the tendon. But again, that's why it's so important to check every strand.
- [29:37]
A
That's a great point. That's what I was. When I would open it up, I would find my sutures had cut through the muscle above. Like I was missing the tendon above. I was going right below in the muscle. That's what I was doing all the time. Yeah, because it felt better going through.
- [29:51]
C
It's easier to go through the muscle.
- [29:52]
A
Yeah, it's like, hey, that feels like a good. A good. Nice.
- [29:57]
C
But yeah, I mean, you're right. It's a learning curve. It's a little bit of a leap of faith because you really are somewhat blinded. And that's why it's so important to check every strand. And it's suture management. There's a lot of suture, particularly when you double lock on both sides. You've got a lot of suture and so you're shuttling sutures this way, that way, and you got to really focus. And if you do that, it tends to work out very well. It's very quick. I mean, if, when you get good at it, not that we're trying to run races or, you know, trying to cut corners, but, you know, I was able to reduce my operative time significantly just because again, you do the technique, you get good at it, you have a good assistant. But then what's really nice is I put those three little sutures in the skin and that's basically my closure. I put one deep suture to close a prayer T9, and then I got three interrupted sutures on the skin and that's it. So it's, you know, for me, it's usually about a 25 minute case. Skin to skin.
- [30:48]
A
Yeah, I am somewhere between 50 and 60 minutes every time, sometimes longer. The closure can be a long time. I'm taking the vical the monochromes in and out. If I don't like it, if it's like the knots coming out, I'm like, I don't want to see any knot under the skin because I've just been through that. So I'm like often redoing some of the monochromes or the fellows monocles.
- [31:12]
B
That concludes part one of our episode on Open versus Percutaneous Achilles Repair. Thanks to co hosts Joe park and Brett Smith and guests Martin o' Malley and Bob Anderson.
- [31:22]
C
Stay tuned for Part two as we continue our discussion. And thank you for listening to the AOFAS Ortho Podcast.
- [31:31]
A
Thank you for listening to the AOFAS Ortho Podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.