Surgical Technique. Achilles Tendon Repair Using Conexa Reconstructive Tissue Matrix. conexatm. Surgical Technique Described by Tom Chang, DPM

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1 Surgical Technique Achilles Tendon Repair Using Conexa Reconstructive Tissue Matrix Surgical Technique Described by Tom Chang, DPM conexatm r e c o n s t r u c t i v e t i s s u e m a t r i x

2 Achilles Tendon Repair: The Achilles tendon attaches the Gastrocnemius and the Soleus muscles to the calcaneus. It is the largest tendon in the body but also the most frequently ruptured, accounting for nearly 40% of all surgically repaired tendon procedures. 1 The ruptured Achilles can become contracted as early as 3 to 4 days after injury so that an end-to-end repair may not be possible. 2 For chronic Achilles tendon ruptures, there may not be adequate viable tendon for reapproximation, making reinforcement necessary. Reinforcement techniques might include gastrocnemius recession, tendon advancement, and tendon autografts and allografts 3. If the ruptured ends of the Achilles tendon are between 2 5 centimeters, a tendon transfer is generally performed during the repair. Several tendons have been used including the plantaris, the flexor digitorum longus, the flexor hallucis longus, and the peroneus brevis. Achilles Tendon For these defects, a V-Y lengthening of the gastrocnemius may also be performed. A gastrocnemius fascial flap procedure is another example of gaining tendon length for a repair. Reinforcement with a tissue matrix may be considered a good option for a chronic Achilles tendon as it adds mechanical and biologic support to the ruptured tendon. The Conexa Reconstructive Tissue Matrix can be used in conjunction with a tendon transfer and/or V-Y lengthening to reinforce the Achilles tendon. Conexa Reconstructive Tissue Matrix is an intact extracellular matrix which supports cell repopulation and revascularization. Conexa functions both as a biologic matrix to support regeneration as well as a biomechanic matrix for load sharing at the repair site*. *Usage of Conexa as a load sharing device has been demonstrated in conjunction with suture fixation as the primary repair. 1

3 Procedure: A standard posteromedial or S-incision is performed along with a layered dissection through the subcutaneous layer to the deep fascia. Care is taken to preserve the paratenon when possible. Fig. 1 Fig. 2 Fig. 3 After identification of the proximal and distal segments of the Achilles, the tendon ends are debrided of damaged and necrotic tissue. Fig. 4 2

4 Primary repair of the Achilles tendon ends is performed using a running, interlocking stitch such as a standard Krackow stitch. #2 high strength non-absorbable suture, such as ForceFiber (Tornier, Inc.), is used to reapproximate the tendon ends. Fig. 5 Fig. 6 3

5 Achilles Tendon Repair Using Conexa Reconstructive Tissue Matrix: Posterior Overlay Procedure Procedure: Utilizing a through and through stitch, a 6 cm x 6 cm Conexa 100 graft (Tornier, Inc.) is secured in place with non-absorbable suture proximally on the lateral and medial sides of the tendon. The graft is then place under tension and fixation distally on the lateral and medial sides of the tendon. A Keith needle can be used to hold the graft in place prior to suture fixation. The graft is then further fixated on both lateral and medial sides with a lateral trap stitch. Fig. 7 Fig. 8 Achilles Overlay Technique using a Conexa cm x 6 cm graft. Conexa Reconstructive Tissue Matrix is positioned proximal to distal over the repaired tendon in a posterior overlay fashion. 4

6 Achilles Tendon Repair Using Conexa Reconstructive Tissue Matrix: Posterior Wrap Procedure Procedure: A 6cm x 6cm Conexa 100 graft (Tornier, Inc.) is positioned lengthwise and centrally around the repaired Achilles tendon. Non-absorbable suture is used to secure the graft circumferentially around the tendon. Proximal and distal sutures are then placed to secure the graft to the tendon. Excess graft material is trimmed as necessary. Fig. 9 Fig. 10 Fig. 11 Achilles Wrap Technique using a Conexa cm x 6 cm graft. Closure: Care is taken to reapproximate the paratenon over the repair site and secure with 3-0 Vicryl suture. The wound is irrigated with sterile saline. A standard layered subcutaneous and skin closure is performed. The skin incision is secured. Fig. 12 Fig. 13 Fig. 14 Surgical photos courtesy of Lindsay Barth, DPM and Jeff Deacon, DPM 5

7 Post Operative Care: Patient is placed in below knee cast with degrees of plantarflexion (post-op week 0 to 3) Cast removed, active and passive ankle motion, nighttime splinting (post-op week 3 to 5) Walking exercise, full immobilization without brace (post-op week 5 to 6) Resisted active and passive motion (week 6) Full-weight bearing, beginning of sports training (week 12) or whenever the patient reaches preinjury levels Summary: Conexa Reconstructive Tissue Matrix provides biomechanical support for the repaired tendon. It also supports tissue regeneration instead of scarring at the repair site. References: 1: Jozsa L, Kvist M, Balint BJ, et al. The role of recreational sport activity in Achilles tendon rupture: a clinical, pathoanatomical, and sociological study of 292 cases. Am J Sports Med 1989;17: : Bosworth DM. Repair of defects in the tendo Achillis. J Bone Joint Surg Am 1956; 38: : Ruch JA, Weinstein, RB. Repair of the Acute Achilles Tendon Rupture. In: Chang, TJ: Master Techniques in Podiatric Surgery: The Foot and Ankle. Vol. 1. 1st ed. Lippincott Williams & Wilkins, 2005: chap 36. Conexa should be sutured to the repair site under tension to provide supplemental load sharing across the standard tendon repair to reinforce the initial stiffness of the repair and minimize early gap formation. Conexa Reconstructive Tissue Matrix can also be used for repair of the following tendons: - Posterior Tibial Tendon - Peroneal Tendon - Lateral Ankle Instability 6

8 conexa reconstructive tissue matrix Product Item No. conexa 100 BCP BCP BCP BCP Product Description Conexa 100 2cm x 4cm Conexa 100 4cm x 4cm Conexa 100 6cm x 6cm Conexa 100 5cm x 10cm conexa 200 BCP BCP BCP Conexa 200 3cm x 3cm Conexa 200 5cm x 5cm Conexa 200 5cm x 10cm Distributed by: Tornier, Inc. Edina, MN USA Manufactured by: LifeCell, Corp. One Millennium Way Branchburg, NJ USA Tornier is a registered trademark of Tornier, SA. This product is covered by US patent: 5, Additional patent(s) pending. CAW-2398 Rev. A