BACKGROUND
Achilles tendon ruptures are traditionally repaired via an open technique or via cast immobilization2. Decreased re-rupture rate has been reported in the literature with open repair as compared with non-operative management1,2. The incidence of delayed wound healing has been reported to be 1-5% and the incidence of wound breakdown and necrosis following open repair as 0.4-2%, which may be reduced using a percutaneous technique3. However, damage to the sural nerve is a recognized complication of percutaneous methods for Achilles tendon repair4-6. Mini-open techniques have been described to avoid the sural nerve with a three incision technique as described by Webb and Bannister.7 More recently, a single incision technique using the Achillon device has been reported12. We present ten achilles tendon rupture repairs using the Achillon® SystemT. This system allows the use of a smaller incision with less complications compared to traditional open repair, an early onset of physical therapy, and a decrease in operative time.

MATERIALS AND METHODS
A retrospective analysis of 10 cases performed for the treatment of acute Achilles tendon ruptures from 2002 to 2006 was performed. Outcomes were assessed by conducting a retrospective chart review of 10 cases, with a minimum of 6 months of follow-up. Components reviewed include: surgical time, type of anesthesia, post-op immobilization, onset of therapy, return to weight bearing, return to unassisted weight bearing, return to activities of daily life, complications, appearance of the operative leg, and plantarflexion strength (ability to perform single heel rise).

Operative intervention was performed utilizing the Achillon® SystemT. Patients were repaired with this system if the tendon rupture occurred 2-8cm proximal to the dorso-proximal aspect of the calcaneus7,12. The patient is positioned prone on the operating room table and is placed under Intravenous sedation. A local block is peformed utilizing 0.5% Marcaine plain. The gap in the tendon is palpated or diagnostic ultrasound is utilized to verify the rupture site and a transverse incision is made just distal to this area10. The incision is deepened via blunt dissection down to the level of the paratenon of the achilles tendon. The paratenon is then incised and the tendon ends are identified. Any areas of tendon degeneration are then sharply debrided. The Achillon® instrument is then inserted in a proximal direction (Figure 1) into the incision. Utilizing a keith needle (Figure 2), 3 separate non-absorbable sutures are placed from medial to lateral through the Achillon® device (Figure 3). The Achillon® device is then withdrawn from the transverse incision leaving the suture within the proximal aspect of the tendon (Figure 3). These steps are then repeated for the distal stump of the tendon (Figure 4). The suture ends are then tied to their corresponding proximal and distal portions (Figure 5) with the foot in slight plantarflexion and appropriate tensioning of the repair. The paratenon is then closed with 3.0 vicryl suture and the skin is closed utilizing 5.0 vicryl (Figure 6). The patient is then placed in a short leg cast at 15-20 degrees of equinus, non-weight-bearing. At the first post operative visit (2-4 weeks), the patient is then transitioned into a cam walking boot for an additional 2-4 weeks with equinus gradually reduced to neutral throughout that period, followed by guarded weight bearing for another 2 weeks. Physical therapy exercises are initiated upon removal of the short leg cast at 2-4 weeks post operative.

RESULTS
10 patients (7 Left, 3 Right) with a diagnosis of acute Achilles tendon rupture were included in the study. There were 9 men, and 1 women with a mean age of 43 years old (range of 33 to 66). All patients were followed for a minimum of 6 months after the repair. The majority of the injuries were sports relatedBREAKDOWN INJURY.? The average time from rupture to repair was 5 days (range of 2 to 15). ?Average total operating room time (patient in room to out of room) was 54 minutes (range of 38 to 79 minutes). Conscious sedation was used in all 10 cases without any requirement for general anesthesia. Post-op immobilization consisted of non-weight bearing short leg cast in equinus for an average of 2.8 weeks (range of 2 to 4 weeks).?Time to initiation of physical therapy was 3 weeks (range of 2 to 4).? Return to assisted weight bearing occurred at 4.1 weeks (range of 2 to 6) and to unassisted weight bearing after 7.7 weeks post-operatively (range of 7 to 10).?Return to daily activities required 9.2 weeks (range of 8 to 16) after the surgical procedure.?Strength of the Achilles tendon was tested by patient's ability to perform a single heel rise (Figure 7), and all patients were able to perform the test at 6 months post-operatively. Complications occurred in 2 patients and included one re-rupture (28 days post op) on a patient who prematurely began non weightbearing without assistance at and one suture abscess. No incidence of Sural nerve injury was noted in our series. Patients were asked to rate the appearance of their operative leg at final follow up, and 9/10 were satisfied with the appearance of their operative leg and scar.

DISCUSSION AND CONCLUSION
Achilles tendon ruptures have been reported in the literature to have an incidence of 18 in 100,000 per year and are believed to be increasing in incidence11. At this time, debate still exists over the best treatment for this condition in regards to non-operative care, percutaneous repair, mini-open repair, and open repair of the tendon rupture13. All of these techniques have their own inherent complications. Although we present a small number of patients in this case review, our results are comparable to those reported in the literature for a mini-open repair10,12,14. We did not experience any incidence of Sural nerve injury although this has been reported in the literature with both mini-open and percutaneous repair4-6,10. Two complications were observed in our series. The re-rupture occurred secondary to patient non-compliance within the early postoperative period, and the suture abscess resolved with local wound care. Early range of motion combined with early physical therapy exercises has been reported in the literature to prevent formation of adhesions, and that it does not predispose patients to a higher complication rate8,11. Most recently evidence suggests that the same applies for repairs to Achilles tendon ruptures9,10. Our results indicate that the use of the Achillon® SystemT in conjunction with early physical therapy is a reliable reconstructive technique for use in acute Achilles tendon ruptures with reduced operating room time, decreased wound complications, equal strength and improved post operative cosmesis.

BIBLIOGRAPHY
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