Ultrasound to Prevent Sural Nerve Injury in Achilles Tendon Repair. A Cadaveric Study
Abstract
Introduction: Minimally invasive techniques are preferred to treat acute Achilles tendon ruptures. They represent an option to avoid integumentary complications, and sural nerve injury is one of its main problems. This study aims to verify the usefulness of ultrasound in preventing sural nerve injury during Achilles repair with percutaneous techniques. Materials and Methods: Study in 12 cadaveric pieces. We recreated an injury at the level of the Achilles tendon, 5 cm proximally to its distal insertion. In one of the cadaver limbs, the sural nerve and/or its satellite vein were identified by ultrasonography. We repaired the sural nerve percutaneously with two needles at the proximal level and two needles at the distal level of the lesion and represented the path of the sural nerve. In the contralateral limb, the sural nerve was not identified by ultrasound. We performed the percutaneous repair of the injuries using the Ma & Griffith technique. Results: In the ultrasound group, no sural nerve injuries were identified. In the control group, two sural nerve injuries were observed (p=0.6). In all cases, the identification of the sural nerve by ultrasound was correct. Conclusion: Ultrasound assistance in the percutaneous treatment of Achilles tendon injuries is an effective and reliable method to prevent sural nerve injuries.Downloads
References
Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A metaanalysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87(10):2202-10. https://doi.org/10.2106/JBJS.D.03049
Yang B, Liu Y, Kan S, Zhang D, Xu H, Liu F, et al. Outcomes and complications of percutaneous versus open repair of acute Achilles tendon rupture: A meta-analysis. Int J Surg 2017;40:178-86. https://doi.org/10.1016/j.ijsu.2017.03.021
Rippstein PF, Jung M, Assal, M. Surgical repair of acute Achilles tendon rupture using a “mini-open” technique. Foot Ankle Clin 2002;7(3):611-9. https://doi.org/10.1016/s1083-7515(02)00040-2
Assal M. Suture mini-invasive du tendon d’Achille: un concept qui a fait son chemin [Mini-invasive suture of
Achilles tendon ruptures: a concept whose time has come]. Rev Med Suisse 2006;2(74):1792-7. PMID: 16927558
Carmont MR, Rossi R, Scheffler S, Mei-Dan O, Beaufils P. Percutaneous & mini invasive Achilles tendon repair. Sports Med Arthrosc Rehabil Ther Technol 2011;3:28. https://doi.org/10.1186/1758-2555-3-28
Clanton TO, Haytmanek CT, Williams BT, Civitarese DM, Turnbull TL, Massey MB, et al. A biomechanical
comparison of an open repair and 3 minimally invasive percutaneous Achilles tendon repair techniques during a
simulated, progressive rehabilitation protocol. Am J Sports Med 2015;43(8):1957-64. https://doi.org/10.1177/0363546515587082
Porter KJ, Robati S, Karia P, Portet M. Szarko M, Amin A. An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device. Foot Ankle Surg 2014;20(2):90-3. https://doi.org/10.1016/j.fas.2013.11.005
Blackmon JA, Atsas S, Clarkson MJ, Fox JN, Daney BT, Dodson SC, et al. Locating the sural nerve during calcaneal (Achilles) tendon repair with confidence: a cadaveric study with clinical applications. J Foot Ankle Surg
;52(1):42-7. https://doi.org/10.1053/j.jfas.2012.09.010
McGee R, Watson T, Eudy A, Brady C, Vanier C, LeCavalier D, et al. Anatomic relationship of the sural nerve when performing Achilles tendon repair using the percutaneous Achilles repair system, a cadaveric study. Foot Ankle Surg 2021;27(4):427-31. https://doi.org/10.1016/j.fas.2020.05.011
Yongliang Y, Honglei J, Wupeng Z, Shihong X, Fu W, Bomin W, et al. Intraoperative ultrasonography assistance
for minimally invasive repair of the acute Achilles tendon rupture. J Orthop Surg Res 2020;15(1):258. https://doi.org/10.1186/s13018-020-01776-6
Severyns M, Andriamananaivo T, Rollet ME, Kajetanek C, Lopes R, Renaud G, et al. Acute Achilles tendon rupture: ultrasonography and endoscopy-assisted percutaneous repair. Arthrosc Tech 2019;8(5):e489-e493.
https://doi.org/10.1016/j.eats.2019.01.007
Lee J-K, Kang C, Hwang D-S, Kang D-H, Lee G-S, Hwang J-M, et al. A comparative study of innovative
percutaneous repair and open repair for acute Achilles tendon rupture: Innovative usage of intraoperative
ultrasonography. J Orthop Surg (Hong Kong) 2020;28(1):2309499020910274. https://doi.org/10.1177/2309499020910274
Lantto I, Heikkinen J, Flinkkilä T, Ohtonen P, Leppilahti J. Epidemiology of Achilles tendon ruptures: increasing
incidence over a 33-year period. Scand J Med Sci Sports 2015;25(1):e133-e138. https://doi.org/10.1111/sms.12253
Huttunen TT, Kannus P, Rolf C, Felländer-Tsai L, Mattila VM. Acute achilles tendon ruptures: incidence of injury
and surgery in Sweden between 2001 and 2012. Am J Sports Med 2014;42(10):2419-23. https://doi.org/10.1177/0363546514540599
O’Brien M. The anatomy of the Achilles tendon. Foot Ankle Clin 2005;10(2):225-38. https://doi.org/10.1016/j.fcl.2005.01.011
Gross CE, Nunley JA 2nd. Acute Achilles tendon ruptures. Foot Ankle Int 2016;37(2):233-9. https://doi.org/10.1177/1071100715619606
Weber M, Niemann M, Lanz R, Müller T. Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment. Am J Sports Med 2003;31(5):685-91.
https://doi.org/10.1177/03635465030310050901
Assal M, Jung M, Stern R, Rippstein P, Delmi, M, Hoffmeyer P. Limited open repair of Achilles tendon ruptures:
a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 2002;84(2):161-70. PMID: 11861720.
Nilsson-Helander K, Silbernagel KG, Thomeé R, Faxén, E, Olsson N, Eriksson BI, et al. Acute achilles tendon
rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med 2010;38(11):2186-93. https://doi.org/10.1177/0363546510376052
Pajala A, Kangas J, Ohtonen P, Leppilahti J. Rerupture and deep infection following treatment of total Achilles
tendon rupture. J Bone Joint Surg Am 2002;84(11):2016-21. https://doi.org/10.2106/00004623-200211000-00017
Majewski M, Rohrbach M, Czaja S, Ochsner P. Avoiding sural nerve injuries during percutaneous Achilles tendon repair. Am J Sports Med 2006;34(5):793-8. https://doi.org/10.1177/0363546505283266
Klein W, Lang DM, Saleh M. The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo Achillis. Chir Organi Mov 1991;76(3):223-8. PMID: 181698
Eid EM, Hegazy AM. Anatomical variations of the human sural nerve and its role in clinical and surgical procedures. Clin Anat 2011;24(2):237-45. https://doi.org/10.1002/ca.21068
Giannetti S, Patricola AA, Stancati A, Santucci A. Intraoperative ultrasound assistance for percutaneous repair of the acute Achilles tendon rupture. Orthopedics 2014;37(12):820-4. https://doi.org/10.3928/01477447-20141124-04
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