Minimally Invasive Repair of Acute Achilles Tendon Rupture Using Gift Box Technique

Document Type : RESEARCH PAPER


1 Department of Orthopedic Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Shahid Beheshti University of Medical sciences,Tehran,Iran

3 Department of Orthopedic Surgery, Alborz University of Medical Sciences, Tehran, Iran


Background: This study aimed to introduce a modified technique for minimally invasive Achilles tendon (AT) rupture repair
using gift box sutures. The preliminary clinical and functional outcomes were investigated among a number of patients.
Methods: In a consecutive case series study, 24 patients with acute AT rupture underwent modified minimally invasive
AT repair using two mini-incisions and gift box sutures. The patients were followed up for 24 months. The AT rupture
score (ATRS) and the American Orthopedic Foot and Ankle Society (AOFAS) measure score were obtained from all
patients. The other measured variables included pain intensity and satisfaction using a visual analog scale (VAS), calf
atrophy, the range of sagittal ankle motion, development of wound complications, sural nerve injury, and re-rupture.
Results: After two years, the mean scores of AOFAS and ATRS were obtained at 83±4 and 81.9±6.3, respectively.
Approximately 87.5 % of the patients regained their previous level of activity. The mean VAS score was 7.7±0.9 regarding
the satisfaction with the outcomes. Moreover, isokinetic testing of plantar flexion and dorsiflexion strength were 82.7±5.8
and 87.7±4.1%, respectively, compared to those of the normal side. The calf atrophy was not statistically significant.
In total, five patients reported pain during their activities. The range of operated ankle motion decreased significantly,
compared to that of the other side; however, the differences were not significant functionally. There was no patient with
wound complications, nerve injury, or complaint about problem with footwear.
Conclusion: Minimally invasive repair of acute AT rupture using two mini-incisions and gift box sutures offers good
functional and clinical outcomes without wound complications which can be usually observed following open repair of
AT ruptures.
Level of evidence: III


Main Subjects

1. Weinfeld SB. Achilles tendon disorders. Med Clin
North Am. 2014; 98(2):331-8.
2. Bruggeman NB, Turner NS, Dahm DL, Voll AE,
Hoskin TL, Jacofsky DJ, et al. Wound complications 
after open Achilles tendon repair: an analysis of risk
factors. Clin Orthop Relat Res. 2004; 427(1):63-6.
3. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen
U. Operative versus nonoperative treatment of 
Achilles tendon rupture: a prospective randomized
study and review of the literature. Am J Sports Med.
1993; 21(6):791-9.
4. Bhandari M, Guyatt GH, Siddiqui F, Morrow F, Busse J,
Leighton RK, et al. Treatment of acute Achilles tendon
ruptures: a systematic overview and metaanalysis.
Clin Orthop Relat Res. 2002; 400(1):190-200.
5. Chan KB, Lui TH, Chan LK. Endoscopic-assisted
repair of acute Achilles tendon rupture with Krackow
suture: an anatomic study. J Foot Ankle Surg. 2009;
6. Khan RJ, Fick D, Keogh A, Crawford J, Brammar
T, Parker M. Treatment of acute Achilles tendon
ruptures: a meta-analysis of randomized, controlled
trials. J Bone Joint Surg Am. 2005; 87(10):2202-10.
7. Buchgraber A, Passler HH. Percutaneous repair of
Achilles tendon rupture: immobilization versus
functional postoperative treatment. Clin Orthop
Relat Res. 1997; 341(1):113-22.
8. Sorrenti SJ. Achilles tendon rupture: effect of early
mobilization in rehabilitation after surgical repair.
Foot Ankle Int. 2006; 27(6):407-10.
9. Majewski M, Schaeren S, Kohlhaas U, Ochsner PE.
Postoperative rehabilitation after percutaneous
Achilles tendon repair: early functional therapy
versus cast immobilization. Disabil Rehabil. 2008;
10. Krackow KA, Thomas SC, Jones LC. Ligament-tendon
fixation: analysis of a new stitch and comparison
with standard techniques. Orthopedics. 1988;
11. Labib SA, Rolf R, Dacus R, HuttonWC. The “Giftbox”
repair of the Achilles tendon: a modification of
the Krackow technique. Foot Ankle Int. 2009;
12. Cretnik A, Kosanovic M, Smrkolj V. Percutaneous
versus open repair of the ruptured Achilles tendon:
a comparative study. Am J Sports Med. 2005;
13. Chana JS, Chen HC, Jain V. A new incision for surgery on
tendo Achillis using a distally-based fasciocutaneous
flap. J Bone Joint Surg Br. 2002; 84(8):1142-4.
14. Chan SK, Chung SC, Ho YF. Minimally invasive repair
of ruptured Achilles tendon. Hong Kong Med J. 2008;
15. 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.
16. Bhattacharyya M, Gerber B. Mini-invasive surgical
repair of the Achilles tendon--does it reduce postoperative
morbidity? Int Orthop. 2009; 33(1):151-6.
17. Calder JD, Saxby TS. Early, active rehabilitation
following mini-open repair of Achilles tendon
rupture: a prospective study. Br J Sports Med. 2005;
18. Winters SC, Gelberman RH, Woo SL, Chan SS, Grewal
R, Seiler JG III. The effects of multiple-strand suture
methods on the strength and excursion of repaired
intrasynovial flexor tendons: a biomechanical study
in dogs. J Hand Surg Am. 1998; 23(1):97-104.
19. Jaakkola JI, Hutton WC, Beskin JL, Lee GP. Achilles
tendon rupture repair: biomechanical comparison
of the triple bundle technique versus the Krakow
locking loop technique. Foot Ankle Int. 2000;
20. Lim J, Dalal R, Waseem M. Percutaneous vs. open
repair of the ruptured Achilles tendon da prospective
randomized controlled study. Foot Ankle Int. 2001;
21. Wong J, Barrass V, Maffulli N. Quantitative review
of operative and nonoperative management of
Achilles tendon ruptures. Am J Sports Med. 2002;
22. Tejwani NC, Lee J, Weatherall J, Sherman O. Acute
achilles tendon ruptures: a comparison of minimally
invasive and open approach repairs followed by early
rehabilitation. Am J Orthop. 2014; 43(10):E221-5.
23. Chen H, Ji X, Zhang Q, Liang X, Tang P. Channelassisted
minimally invasive repair of acute Achilles
tendon rupture. J Orthop Surg Res. 2015; 10(1):167.
24. Huri G, Bicer OS, Ozgozen L, Ucar Y, Garbis NG, Hyun
YS. A novel repair method for the treatment of acute
Achilles tendon rupture with minimally invasive
approach using button implant: a biomechanical
study. Foot Ankle. 2013; 19(4):261-6.
25. He ZY, Chai MX, Liu YJ, Zhang XR, Zhang T, Song LX, et
al. Percutaneous repair technique for acute achilles
tendon rupture with assistance of kirschner wire.
Orthop Surg. 2015; 7(4):359-63.
Volume 7, Issue 5
September 2019
Pages 429-434
  • Receive Date: 15 July 2019
  • Revise Date: 07 August 2019
  • Accept Date: 09 August 2019
  • First Publish Date: 01 September 2019