Abstract
Introduction
Minimally invasive Achilles tendon repair has recently gained popularity amongst foot and ankle surgeons. This study aims to quantify the risk of sural nerve injury when using the Achillon device (Integra), as well as delineate its anatomical relationship to the Achilles tendon.
Methods
In 15 cadaveric specimens, the Achilles tendon was transected through a 2cm transverse incision made 4cm proximal to the palpable Achilles tendon insertion point. The Achillon device was inserted beneath the paratenon both proximally and distally and six needle passers mounted with sutures were introduced percutaneously into the tendon (x3 proximal and x3 distal). We dissected around the Achillon jig to determine whether the needle and suture had punctured the sural nerve. We also documented the position of the sural nerve in relation to the Achilles tendon.
Results
The mean horizontal distance from the Achilles tendon insertion to the sural nerve was 22.5mm (15.9mm–30.2mm). The mean vertical distance from the Achilles tendon insertion to the point where the sural nerve crosses the lateral border of the tendon was 96.1mm (77.4mm–134.9mm).
In 4 out of 15 cadaveric specimens (27%) the sural nerve was punctured. In total, the sural nerve was punctured 6 times (twice in 2 specimens) in 90 needle passes (6.7%).
Five out of the 6 punctures occurred when the Achillon device was inserted into the distal tendon portion with the most proximal hole being responsible for 3 of the punctures.
Conclusions
The sural nerve displays a highly variable anatomical course and our findings highlight a significant risk of puncture during percutaneous Achilles tendon repair using the Achillon device. More studies are needed to clarify whether this risk equates to a significant clinical problem and whether a change in technique or instrumentation can decrease this risk.
