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Marie Williams, DPM
Director, Podiatric Medical Education
Aventura Hospital and Medical Center
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Male Speaker: Is Dr. Marie Williams. She has been on our platform many times. She is a dear friend of mine from Florida. Largely involved in podiatric education, residency director, fellow at the American College of Foot and Ankle Surgeons, board certified in foot, ankle and reconstructive surgery. And I’ve asked Marie to talk about the repair of Achilles tears with the use of bone anchors. So we saw an earlier approach of repair of the Achilles rupture. Now, we’re going to look at tears and down at the insertional area and how you can reattach the Achilles most effectively. So please welcome Dr. Marie Williams.
Marie Williams: Good morning. I’m going to actually go over a lot of bone anchors with you. When I put this together with my residents, it was interesting to see that there are so many anchors out there. When we started using bone anchors, we had one. We had a Mitek anchor and we thought we were really cool because we could use them. And if you will see this lecture, you’ll see that there are so many anchors that we’ll use to put Achilles tendons back and why we should use them and what the benefits are of each type. When you repair an Achilles tendon with bone anchors, you’re looking at a tendinosis or a tendonitis and possible partial tears. And there’s all types of anchors out there. When you’re there and you’re attending or if you aren’t attending, you say, “I need a bone anchor,” now you have to be very specific on what kind, what type, what thread and why. So I’m going to hope to give you a little bit of insight on how many there are. What will happen in most of the times, we’ll get used to your own type and you’ll use that probably more frequently. But there’s a reason for each and we’ll go over them. When you talk about tendon pathology, Achilles tendinosis, we will go over a little bit about the thickening of the tendon, insertional problems and we’ll review all of the different types of tendonitis and tendon tears in the Achilles and you’ll understand the mechanism as well. Hopefully I won’t repeat anything about what you saw earlier this morning, but I can’t give you a disclaimer on that. Tendinosis, what is it? It’s usually caused by chronic degeneration and change in the tendon with very little pain. What you’ll see is a thickening of the tendon in the posterior heel. Sometimes you won’t even see it until you touch the tendon and the patient will say it hurts exquisitely right at the lower portion of the Achilles. It’s due to microtrauma to the tendon, it’s absolutely due to an overuse syndrome, a lot of times in tennis players, Wigan Warriors, who play tennis, basketball, soccer, all seen in all types of sports. And then also the natural aging process of the tendon, the blood supply decreases. After 30, the collagen fibers in the blood supply of the tendon decrease significantly so you have higher rate of tear pulls and inflammation in the tendon. Tendinosis doesn’t really cause as much degenerative change as a full tear from the tendonitis. What it does is it causes a chronic change in the tendon itself. Here’s an example of someone with a small area of the tendon bulge posteriorly, there’s no real significant change on X-ray. But within the tendon itself, it is exquisitely painful. And these types of problems become difficult because you’re going to try to repair them, but you can’t really inject them very well with steroids because you don’t want to re-rupture the tendon or tear it again. Offloading and management is important, physical therapy is important. You don’t want to overstretch them but you want to stretch them so it becomes a very difficult process. In tendonitis, it’s really a symptomatic degenerative change of the tendon. It’s an inflammatory process within the tendon itself. Chronic tendonitis is usually caused with an inflammatory reaction within the paratenon which is different than a tendinosis. And adjacent synovial structures become very inflamed. There’s disruption of the normal tendon glide in a tendonitis. The tendon tears are most commonly due to a direct trauma, maybe a recurrent inflammatory process. Biomechanical dysfunctions. For example, posterior tibial tendon dysfunction, peroneal tendon disease, equinus. And you’ll also see it in tendon tears and Achilles tendons and tendonitis. This is an example of someone who has two different types of tendon tears. This is a longitudinal thickening tear of the Achilles tendon on your right and on your left. It’s actually within the substance of the tendon, not the insertion. And you’ll see a ball of what appears to be non-disorganized collagen fibers within the tendon itself.
And these are types of tears you’ll see sometimes with the Haglund’s deformity, or just within the tendon substance. I’m not going to repeat this so we’ll go past this pretty much quickly. Tendon ruptures are usually spontaneous, most commonly between the third and fifth decade of life. And it is more common in men than women. And it’s from the professional athlete to the Wigan Warrior. I personally always have that vision in mind of, I don’t know if you guys are old enough to remember Dan Marino going for a pass and all of a sudden, he falls to the ground when no one touched him. He had an Achilles tendon rupture spontaneous. A high-end professional athlete and now what happens, these guys spend a lot of money keeping themselves in really incredible shape and that tendon just popped. It’s sometimes career ending for these athletes. So it’s just a good example, though sometimes you’ll feel a pop in the calf, you’ll feel like you’ve been shot in the leg. In my area, sometimes you are shot in the leg. But actually the tendon really pops or pulls. The muscle becomes very tender, inflamed. They grab their leg almost just like that. I’ve seen people on the tennis court, obviously when you turn around, you’ll go, “What happened?” They’re lying on the ground. They were just standing there. And it can be that spontaneous. Generalized symptoms are pain with exercise, pain and swelling along the tendon when you palpate it. It’s usually at the beginning of activity. And in these tendinosis type problems, it gets better as you warm up. You have increased blood flow to the area and that’s why it’s better when you warm up. Over time, it becomes a dull ache and sometimes occasional weakness. So when you see someone walk in your office or you’re doing a gait analysis, they tend to have a slight limp and you will wonder, why are they walking like that. It’s because the tendon that’s now thickened and scarred becomes what you call a tendinosis and it becomes a bit weaker than the opposite tendon. This is just the typical test for the Thompson test or Thompson and Doherty test where you’ll squeeze the affected Achilles tendon and the foot will not plantar flex. It’s just a good indicator of Achilles tendon rupture. Most of the time, you’ll use your hands to palpate. You don’t need an MRI to know that it’s a defect. What you need an MRI for is to know how much of a defect. And you can palpate that and you can see the swelling and the disruption of the tendon. Why bone anchors? Well, this is just another piece of the puzzle to repairing the Achilles. So before you can use an anchor, you need to know what’s out there. What I did is we put together what is an ideal anchor. An ideal anchor is something that’s easy to use. In my mind, anything that you can use in the operating room that is quick and easy, that you don’t have to think about a lot, makes your operative procedure much less stressful. You want something that’s adequately strong with good range of motion and function to the tendon itself. So you don’t want a big thing that's going to block tendon motion and/or strength to the tendon. And it can be replaced by a bone host and/or allows for normal restoration of the mechanical function at the soft tissue bone interface. That’s very important. So that makes an ideal anchor. There’s all types of anchors. There’s the PGA which we used early on and we’ll go over that polyglycolic acid. And then the PLLA came out because the PGA was just a little bit too difficult to break down. And then we advanced into PEEK which is what you see most commonly for yourselves is the polyether ether ketone. And then you have the metallic ones that are now stainless steel and/or titanium. So there’s different categories and different types and the ones you’ll see most commonly now are the PEEK and the metal, and some of the PLLA. I can tell you on the PGA, we had bone pins that I probably did a thousand bunions with these bone pins. And I had maybe two or three reactions. For me, personally, it wasn’t like, “Oh, no, this is going to react poorly.” But time changes what you use sometimes and the industry changes to better itself. The PGA went out of favor and the PLLA came into favor. So I just want to let you know that. Some of the complications to the anchors, cyst formation around the anchor itself, and I’ve seen that. It’s not fun when you see that. It looks infected. It’s usually a sterile abscess. You’ll have a large cystic lesion with a fluid-filled cyst and it’s usually due to the actual anchor being reabsorbed.
You have soft tissue inflammation. You’ll have loosening of the implants. So now what you put in isn’t really working. And then you’ll get localized osteolysis and that’ll happen when you’re actually getting reabsorption from the actual absorbable anchor or pin. PGA was the first-generation absorbable implants and it absorbs very fast. That’s why I personally liked it for bunions. But the absorption rate being very fast maybe wasn’t ideal for tendon attachments. It degraded fast, absorbed fast and it caused firm body reactions, which as I’ve said, when you see them, you’ll never want to use them again because they’re very violently reactive in the sense that you’ll get a large cystic lesion in the bone. And now, you have to fill it with new bone, you have to take it out, this becomes a very arduous type process for a little pin or anchor that you thought was not invasive. PLLA is a second generation of absorbable implants. It absorbs slower which was an advantage when you did tendon to bone insertion. It didn’t degrade as fast and it had a less firm body reaction. So that was better. We’re improving. And then the PEEK came out and it’s an injectable mode for a mass fabrication, it’s radiolucent. It increases the holding capacity in strength around the bone tendon interface. It’s less risk for eyelet rupture which may or may not have ever seen this, but sometimes the eyelet weakens and then the thread pulls out and then you have an anchor in the bone but you don’t have enough tendon to the bone anchor. So that’s a problem, right? You have a premature degradation and pullout. This is a less risk of osteolysis because it’s more inert to the body and it doesn’t absorb so you don’t have reabsorption problems. And then you have a bone anchor composite. We have the titanium, the bioabsorbable, the PEEK, some of these are actually composites or mixed, so that you’ll have those as a benefit. What did it look like? Here’s a titanium wedge anchor. Now, I’m going to represent as many anchors as I can from as many companies. I’m not for one company here when it comes to bone anchors. I just want you to know how much is out there. Because if you don’t know what’s out there, then how are you going to decide which one you’re going to use and why, right? You actually could do this yourself in your own hospitals, see what’s on your shelves, see what company your hospital is contracted with. The world of implantation and metal materials and things have changed now because hospitals are contracting with certain companies, companies are buying other companies. It’s no longer get Joe [Phonetic], he’s going to come in and give me an anchor. It’s no longer like that. So you have to understand what you have in your hands and what’s available to you. And hopefully you’ll have an opportunity to select and pick. This titanium wedge anchor is a rounded eyelet for smooth suture sliding and gliding, and it’s a vertical base, a little vertical base that anchors well with a good eyelet connection, so that it doesn’t have easy pullout. Here’s another one by Stryker, it’s the Titanium IntraLine anchor. And it comes in 5.5. and 6.5 millimeters. It’s available with and without the needles. It’s loaded with two strands of the number two force fibers. Now, every fiber is different. Each company has a different thread fiber and type of fiber. So you have to understand the threads, because you also have thread reactions which I’ll show you. These are fully threaded anchors with the internal soft suture eyelet and it’s excellent for arthroscopic type surgeries. Again, Stryker has their BioZip which is a trocar tip for easy insertion. It has a separate suture channel for easy knot tying and it is bioabsorbable. So just another one. So we only got through three or four that you can see how many different types already and different kinds and why. Then there’s the PEEK. Now we have the PEEK which is a fully threaded anchor with the suture eyelet. It’s excellent for arthroscopy and open cases and it’s available with and without needles. They’re now coming into their PEEK evolution. And they have the PEEK Zip. It looks like Stryker is our number one with so many different anchors but don’t settle on that yet. Because Wright Medical then has all their G-FORCE and they have the high pullout strength PEEK, which is available in many different sizes from four millimeter up to 10 and 15 millimeter.
And it is actually a very good non-absorbable powerful anchor that has high pullout strength. So you can see how many they have there. And then the Wright Medical also has the quick draw to knotless system for soft tissue fixation and it’s combined with three unique elements to provide a simplified but reliable technique. It has their own little way of putting it in there, but it’s basically the suture materials, the high-ultra-molecular-weight polyethylene. And, that may have some benefits and it comes in various sizes. You may want to use that anchor. It has the little wings on it so that the pullout is very difficult. So once it’s in there and the wings pop out, the pullout strength is very high. That’s the quick draw. Then you have the SPEEDSCREW by Opus and it’s a PEEK also and knotless. They also have a non-PEEK but that I use the PEEK. Fully-threaded bone fixation system which maximizes pullout strength. And it has an interdependent tensioning device which is like using a reel on a fishing pole. If you like to go fishing, this is a good one. The implant doesn’t rely on the bone quality which is important because sometimes in diabetics, the bone quality is poor and you may have an Achilles tendon tear in a diabetic. So this might be something that you might want to use. Now, you have Biomet, it’s called the JuggerKnot. It’s actually a loaded number one Max brand which is their brand type thread. And it actually has tapered number five needle. It’s a needle of system, it’s a number five tapered material that actually goes within the bone itself. It’s made from polyester suture. It eliminates the possibility of a rigid material loose body formation, although I have seen that people who are allergic to polyesters might have a problem with this. So just be aware of that. Biomet has the Rattler. It retains 80% strength at eight weeks. It’s fully reabsorbed in 12 to 14 months and it provides lasting strength throughout the healing process. Now, have you been totally confused on which one you’re going to use? At least know they’re all out there, right, because there’s more. Here’s the ZipTight. This is actually something that a lot of guys use for their syndesmotic tears. It’s low profile to help avoid irritation. Some of these knotless systems are good, a ZipTight or like this, like Biomet is a MaxBraid, again, suture. It has two buttons, it’s easy to use. One of the things that I like about these types of fixations is you don’t have to go back in and take out the screw if you’re doing an interfrag type treatment. ConMed is the Y-Knot. There’s another one, it’s 360 degrees, FormFit fixation, 1.3 millimeters in thickness, a high strength type of suture fixation. It has the anchor context vertically and expands laterally so you have 189 newton of pullout strength. I have not ever used this one, but that’s for completeness sake, you’ll see that one. Arthrex has the FASTak, which sometimes you’ll just pull off the shelves, stick it in, if Arthrex is in your hospital. It’s smaller, non-absorbable. They have the braided polyblend. It’s definitely a very simple one to put in. There’s a titanium with FiberWire. FiberWire is the trademark for Arthrex. Now, if you look at Arthrex, they have all types of knotless systems from PEEK to the bioabsorbables, to the metal and titanium. You have the SwiveLock. You have the corkscrew, the pushback, there’s definitely different types. So anything that you need and Arthrex is on your shelf, they have those available, too. DePuy, DePuy has several that are out there. You can see that there’s also the GII QuickAnchor. They have the metals and they have this different type of thread that they use. So everyone has their own little proprietary thread and materials that they use to bone anchor the tendons. BioPro has a new system out there and it’s actually something that I wanted to present just in actually a quick passing is it’s a tendon anchor system that’s good for tendon-to-bone interface.
It’s a single hole or two-holed design and it’s a low profile and an offset design with teeth. It has teeth that actually take and pull the tendon to the bone and then you can put a screw in there and it penetrates the tendon to resist a pullout. It also has the blunt teeth which don’t penetrate to the bone, but actually into the soft tissue itself. And you can see here on the bottom, there’s a little graph. It just shows that there’s a high pullout strength with this product without all the thread, which can be an advantage, and I’ll show you why. Surgical intervention, whenever you’re doing this, the goal is always to restore the preinjured strength and function. Whenever you’re doing any type of surgery, you’re trying to restore strength and function. And usually done after conservative treatment has failed in this tendinosis. The recovery time can take up to four to six months due to the reorganization of collagen in the damaged tendon. Let’s just take a look at a couple. This is a longitudinal tear repair. This is actually where you go in and you repair it. And you may use an acellular dermis on this. You can see that’s where we actually take out all the scar, put the tendon back and then we use an acellular dermis. This person also had a tarsal tunnel, that’s why the other scar. This is actually a Haglund's type problem but the tendon is torn from the bone. And you see here, this is all scar from the tendons. When you open it up, not only do you have to take away some of the bone, you have to anchor the tendon back to the bone. And now, it’s really your choice of anchor. And here we are using a bone anchor thread system that’s going to go right into the bone tendon interface. And you can see it here. And then I always repair my tendons with an acellular dermal matrix because it provides lack of scar and increased strength. And you can see that tendon is now replaced back. Here’s an old scar of the tendon in the heel spur. This is actually someone who’s had four different surgeries on her heel. And the tendon is all disorganized. And you can see here, it’s all striated. So we actually repair it, remove a lot of the necrotic debris, or reanchor it to the tendon. What I’m showing you is debridement of the tendon which has to be done. There’s the large spur. That’s taken off. The spur is down and this is a non-absorbable. You can almost see the anchor in there holding the tendon and the bone. Tendinosis, just a quick, tendinosis, sometimes I’ll just use amniotic membranes and inject them. This is a before and after within four weeks. Insertional tendinosis, again, you’ll see this large protuberance in the back of the heel. We’ll remove the bony prominence. You’ll remove the tendon from the bone. And then you’ll use an anchor system to anchor that tendon back. Prior to anchor systems, it was a difficult procedure, you tried not to remove the tendon, tried not to touch or remove the Achilles tendon. You’re working around it. Now, you just cut the tendon, take off the spur, put the tendon back, the anchors are so strong that you know that your pullout or your re-rupture or your surgical rupture that you create is going to be repaired well and held them close as long as you have a good anchor system in place. This is an Achilles tendon rupture. Why am I showing you this? I’m going to show you this because a person ruptured it in the substance of the tendon and then re-ruptured it at the heel and pulled the bone off. So I’ll just show you that really quick. Here is the tendon pulled off from the bone and we’re opening that up. We’re going to open it up all the way to the heel. When you do that, you have to actually now repair that whole Achilles back into the bone. You can see the drill holes where the anchors are going. In the tendon, we use our Krackow type stitch. And then what we’ll do is we’ll take and put the anchors in and that thread is then threaded through the anchors down into the bone and tension. Now, you have a good repair of that ruptured Achilles from the bone itself. And there it is. And as I’ve said, once I actually repair it back, let me back up a second, I’ll just use an acellular matrix to reduce scar, increase my strength in my repair. Here’s another anchor system where you’re now just drilling into the heel. I’ll use two holes. Sometimes I’ll use them top to bottom or side to side, depending on the type of injury of the Achilles. But you’re now putting an anchor into the Achilles and then you’re going to thread the anchor through the tendon to the bone. And you could see that there. This is a tensioning device that is used to actually thread the threads through by turning a little dial in, it’s like going fishing.
And there you go. This is an Achilles tendon with a large posterior spur. And you’ll see these tears with those spurs, not uncommon. So you’re taking the fragment of bone out, which is an insertional tendinopathy with the large spur, which is very, very painful. Conservative treatment really doesn’t work well in an active person. And then once you do that, we use the knotless system here. This is actually a grasper or a biter, it just bites into the tendon and then that will load the thread. And then here is the drill that you’re drilling in once the thread is loaded. And you can see here that you’re putting it into that little pin site, that loads the thread to the device that’s going to anchor the tendon to the bone. And there’s the thread threaded without a knot. And then you’re going to just dial it in. And now, that’s the thread that we’re going to cut away with the tendon attached to the bone. And that’s the knotless system. Why consider something that is a non-threaded device that can insert a tendon to bone? Well, here is why. This patient had a reaction to FiberWire. That’s not saying FiberWire is bad, it means that when you have a reaction to it, that’s bad. You have this open non-healing wound that drains constantly. It’s very painful. We opened it up and looked at the hole in the tendon. That’s the FiberWire, the hole where the FiberWire was just in through the tendon. And so, this tendon was not only destroyed but it also tore again. So we had to repair the tear, repair the reactive tissue and then get it back down so that it could be functioning again. This took a long time because this reaction seemed to never want to go away. We’re pulling FiberWire out for a very long time. So that’s the tendon being repaired once we have the tendon in place. And we can see here that we’re doing a tendon repair to itself. I’ll use acellular dermal matrix to reinforce it. And it double. Now, there’s a second piece on top because I know with certainty that this wound will dehisce. And since I know acellular dermal matrix is great for wound healing, we also had that in mind. So we not only cover the tendon but we use that little piece because that was where it was a high-tension area, where it would probably break down. That brings me to the TAS plate for insertional Achilles tendinosis. If you’re worried about the thread types, possible reactions, and/or you get a reaction and have to remove it, this is a great alternative for repair to the bone. Here it is in place. It’s actually like a brace that will brace the tendon to the bone with screw fixation. So that you have no threads or very little foreign body material reaction and this is a titanium type material that’s very inert to the body. It’s actually something that should be considered not only for Achilles but they have now one for posterior tib tendon repair and/or any type of tendon tear off from the bone. Just another example of how that plate looks with it in place. So you can see here, it’s like a little brace. It is low profile, although it may not look low profile on that picture. It sits in the posterior superior aspect of the heel so that you don’t get pressure from the back of the heel. Just as an aside. My tendon tears, whether I do anchors or not, is very much the same, three weeks in a nonweightbearing CAM boot or cast. Yes, we do DVT prophylaxis. Yes, we use ice therapy, three weeks partial weightbearing in a CAM boot and then active range of motion in six week, six to eight weeks return to full weightbearing. If they can’t go full weightbearing in six to eight weeks, we go partial weightbearing in CAM boot until they get strong and use active physical therapy. Here are some references for you for all the different types of anchors and systems. Hopefully this will give you an opportunity to make some educated decisions on what you’re going to use in the future. There are so many out there. Since I put these together a couple of weeks ago, I tried to add in anything new. Who knows, something is new out there. So be aware, always be read, always stay educated. Thank you.