Foot and Ankle Surgery 19 (2013) 261–266

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

A novel repair method for the treatment of acute Achilles tendon

rupture with minimally invasive approach using button implant:
A biomechanical study
Gazi Huri MDa,b, Ömer Sunkar Biçer MDa, Levent Özgözen MDa, Yurdanur Uçar DDS,
MS, PhDc, Nickolas G. Garbis MDb, Yoon Suk Hyun MDb,d,*
a
Department of Orthopaedic and Traumatology Surgery, Cukurova University, Adana, Turkey
b
Department of Orthopaedics and Traumatology Surgery, Division of Sport Medicine, Johns Hopkins University, Baltimore, MD, USA
c
Department of Prosthetic Dentistry, College of Dentistry, Cukurova University, Balcali, Adana, Turkey
d
Department of Orthopaedic and Traumatology Surgery, Hallym University, Chuncheon, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Article history: Background: Minimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low
Received 10 April 2013 rate of complications. However there are still controversies about optimal technique. In this study we
Received in revised form 15 May 2013 aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair
Accepted 25 June 2013
technique and evaluate its biomechanical properties comparing with native tendon and Krackow
technique.
Keywords: Methods: 27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens
Endobutton
ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in
Achilles tendon
Acute
group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including
Rupture native tendons. Unidirectional tensile loading to failure was performed at 25 mm/min. Biomechani-
Repair calproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and
Minimally invasive Young’smodulus (GPa) was measured for each group. All groups were compared with each other using
one-wayANOVA followed by the Tukey HSD multiple comparison test (a = 0.05).
Results: The average peak force (N) to failure of group 1 and group 2 and control group was 415.6  57.6,
268.1  65.2 and 704.5  85.8, respectively. There was no statistically significant difference between native
tendon and group 1 for the amount elongation at failure (p > 0.05).
Conclusions: Regarding the results, we concluded that Endobutton-assisted modified Bunnell technique
provides stronger fixation than conventional techniques. It may allow early range of motion and can be
easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality
tendon at the distal part of rupture.
Level of evidence: Level II, Biomechanical research study.
ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction results in increased granulation tissue, delayed healing, and

Among all sports injuries, Achilles tendon rupture has a
substantial potential to cause significant morbidity. Only 50–
60% of elite athletes are able to return to their pre-injury levels
following the injury [1,2]. Recent studies in the literature suggest
early weightbearing mobilization and strengthening exercises to
accelerate time of return to sport, which may expose excessive
stress and gapping at the repair site [3–10]. Tendon gap formation
* Corresponding author. Current address: University Department of Orthopaedic
and Traumatology Surgery, 10753 Falls Road, Suites 215, Lutherville, MD 21093,
USA. Tel.: +1 410 583 2850/213 379 1783.
E-mail address: yhyun1@jhmi.edu (Y.S. Hyun).
compromised strength of the repair site, and it may ultimately
compromise the final clinical outcome [8]. Lee et al. [11] reported
that more than 5 mm of gapping might be considered an important
parameter for clinical failure. Tendon gapping may also compro-
mise the clinical outcome with excessive granulation tissue
formation at the repair ends, which impairs strength of the repair
site [11]. Furthermore, weakness in end-range plantar flexion after
Achilles tendon repair has recently been attributed to excessive
tendon lengthening during muscle contraction [12]. In response to
these problems, multiple suture techniques and surgical proce-
dures such as open, percutaneous and endoscopically assisted
techniques have been described to minimize impairment during
early rehabilitation and weight bearing mobilization [5,9,13–16].
In recent studies, minimally invasive repair has been proposed

1268-7731/$ – see front matter ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.fas.2013.06.012
262
G. Huri et al. / Foot and Ankle Surgery 19 (2013) 261–266
over open repair as a reasonable treatment option for acute
Achilles tendon rupture with a low rate of complications [9,15,17].
However, there is no clear consensus regarding the optimal
surgical technique for acute ruptures of the Achilles tendon.
Regardless of technique, it is important to design a strong
suture construct to allow early weightbearing mobilization and
strengthening exercises without compromising the repair, as well
as to avoid wound complications. The purpose of this study was to
describe and evaluate the biomechanical properties of a new
minimally invasive technique using Endobutton (Smith&Ne-
phew1, London, UK) assisted modified Bunnell suture for acute
Achilles tendon ruptures. This novel technique has the potential to
minimize the complications and provide more biological healing
since it does not involve exploration of the rupture site. We also
compared our results against the native tendon as the positive
control and tendons repaired with the conventional Krackow
technique [18]. Our hypothesis was that Endobutton-assisted
modified Bunnell configuration will provide failure strength near
native tendon and will be stronger than the Krackow technique.
2. Materials and methods
Twenty-seven ovine Achilles tendons including musculotendi-
nous junction proximally and entire calcaneus distally were
obtained less than 24 h after sacrifice and were kept moist with
normal saline at room temperature. The ovine individuals were all
male Merino Wether sheep with an average age of 1.5 years, and an
average weight of 48.5  2.8 kg. The tendons were randomly placed
into 3 groups with 9 specimens in each as; Group 1 (Endobutton-
assisted modified Bunnell technique) (Fig. 1), group 2 (Krackow
suture technique) (Fig. 2) and group 3 (control group – native
tendon). Biomechanical properties of the native tendons were
measured and the most common rupture locations were recorded.
Using the information from rupture level in group 3, the tendons in
both groups 1 and 2 (18 tendons) were prepared by cutting 2 cm
proximal to the calcaneal insertion and repaired using the two
different suture configurations.
3. Repair techniques
3.1. Group 1 (Endobutton-assisted modified Bunnell technique)
The insertion of the Achilles tendon on the calcaneus was
[(Fig._2)TD$IG]exposed, taking care to preserve the tendon attachment on the
Fig. 2. Illustration of Krackow suture technique.
[(Fig._1)TD$IG]
Fig. 1. Illustration of Endobutton-assisted modified Bunnell technique.
calcaneus. A 3.2 mm suture passing pin was inserted through the
calcaneus from proximally to distally (Fig. 3a). A 4.0 mm
cannulated drill was used over the passing pin to create the
transcalcaneal tunnel. Then, No. 1 Ethibond suture (Ethicon Inc.,
Somerville, NJ) loop was threaded through the eyelet of the passing
pin. The passing pin was advanced into the transcalcaneal tunnel
and pulled out of calcaneus distally (Fig. 3b) to pass the loop,
leaving its free limbs proximally (Fig. 3c). Afterwards, No. 2
Ethibond (Ethicon Inc., Somerville, NJ) suture, which is mounted on
the Endobutton (Smith&Nephew1, London, UK) was loaded into
the loop and pulled proximally through the transcalcaneal tunnel
(Fig. 3d). Finally the Achilles tendon was repaired using modified
Bunnell technique with No. 2 Ethibond suture, which was
described by Carmont and Maffulli [16] (Fig. 3e).
3.2. Group 2 (Krackow suture technique)
All tendons were repaired using the Krackow technique (triple
locking loops) with No. 2 Ethibond (Ethicon Inc., Somerville, NJ)
which has been shown to be substantially stronger than both
Kessler and Bunnell suture techniques [19].
In both groups the repairs were augmented with a running
peripheral suture (3/0 Prolene, Ethicon Inc., Somerville, NJ).
3.3. Biomechanical evaluation
All biomechanical evaluations were done on the same day
following repairs to avoid structural changes before testing. Each
specimen was placed into a universal testing machine (Testo-
metric M500-25AT; Testometric Co., Ltd., Rochdale, UK). Clamps
were used to secure the tendon proximally and the calcaneus
distally (Fig. 4). Prior to biomechanical testing, pilot tests were
performed in 5 additional specimens to ensure no tendon slipping
or tearing at the clamps. Unidirectional tensile loading to failure
was performed at 25 mm/min [20]. Force displacement values
analyzed included peak force to failure (N), stress at peak (MPa),
elongation at failure, and Young’s modulus (GPa). Definition of
failure was more than 5 mm gap formation at the repair site
[21,22].
A statistical software package (SPSS 17.0,Cary, NC) was used for
analysis. Before comparing the groups, Cronbach’s alpha was used
to determine the internal consistency of the measurements and
measured as >0.70, which was considered as reliable. Peak force to
[(Fig._3)TD$IG] G. Huri et al. / Foot and Ankle Surgery 19 (2013) 261–266 263

Fig. 3. Endobutton-assisted modified Bunnell technique. (a) 3.2 mm suture passing pin (white arrows) was inserted through the calcaneus from proximally to distally (b) the
passing pin was advanced into the transcalcaneal tunnel and pulled out of calcaneus to carry the loop (asterisk) distally (c) the loop (asterisk) was carried to plantar site,
leaving the free limbs proximally (d) the sutures mounted on Endobutton were passed through the tunnel by the assistance of the loop (e) Final appearance of the specimen
repaired with Endobutton-assisted modified Bunnell technique.
[(Fig._4)TD$IG]
failure (N), stress at peak (MPa), percent elongation at failure, and
Young’s modulus (GPa) were compared using one-way ANOVA
followed by the Tukey HSD multiple comparison test (a = 0.05).

4. Results

The average distance of ruptures from the calcaneal insertion in

Fig. 4. Measurements were done on a universal testing machine (Testometric
M500-25AT; Testometric Co. Ltd., Rochdale, UK). Clamps were used to secure the
tendon proximally and the calcaneus distally.
native ovine tendons was 19.6 mm (SD  1.78). The average
diameter of the rupture site was 9.8 mm (SD  0.89) with no
statistically significant difference between the groups (p > 0.05). The
average ultimate force (N) to failure of the control group was
704.5  85.8. The average ultimate force to failure of the group 1 and
group 2 were 415.6  57.6 and 268.1  65.2, respectively. Although
ultimate force to failure was significantly greater for group 1
compared with group 2 (p < 0.05), both groups were significantly
weaker than native tendon (p < 0.05). (Fig. 5) The average stress at
peak (MPa) of the control group was 44.2  5.6, while the both groups
were 25.5  4 and 18  4.3 respectively. This indicates a greater
stress resistance value at failure for group 1 versus the group 2
(p < 0.05). There was no statistically significant difference between
native tendon and the group 1 for the amount elongation at failure
(p > 0.05), but was higher in group 2. (p < 0.05).
Young’s modulus (GPa) of the control group, group 1, and group
2 were 139.6  46.7, 68.9  23.4 and 43.5  34.3, respectively.
Young’s modulus of native tendon was statistically higher than the
two groups (p < 0.05), however there was no statistically significant
difference between group 1 and 2.
[(Fig._5)TD$IG]
264 G. Huri et al. / Foot and Ankle Surgery 19 (2013) 261–266
Fig. 5. In the graphics all data are shown as mean with SD (CI: confidence interval).
5. Discussion
While the ultimate failure force at the repair site after Krackow
suture technique was only 38% of the native tendon’s failure force,
Endobutton assisted suture technique provided two times more
failure resistance at the repair site than Krackow technique.
Even though the ultimate strength of repair obtained by the
Endobutton technique is not equal with native tendon, it is more
likely to resist rupture than the Krakow technique. When
comparing human cadaveric data to ovine data, it has been
shown that the load across the human Achilles tendon in neutral
position is 370 N, and will increase to 400 N with passive ROM
[23]. Our average force to failure was 415 N using an ovine
model. This comparable result may support the clinical meaning
of our technique. To our knowledge, this is the first study that
tests biomechanical properties and describes the operative
technique of Endobutton assisted modified Bunnell technique
for Achilles tendon ruptures.
Endobutton techniques have been widely used for the
treatment of several injuries such as acromioclavicular separation
[24,25], distal biceps brachii rupture [26,27], distal tibiofibular
syndesmotic injury [28–30] and reconstruction of knee ligaments
[31,32]. The use of an Endobutton has not been previously
described for the treatment of acute Achilles tendon ruptures in
the literature. Fanter et al. demonstrated the safety of transcalca-
neal drilling during Endobutton use and also demonstrated good
biomechanical results of Endobutton-assisted repairs combined
with double-row suture anchor construct in the treatment of
insertional Achilles tendinopathy in a laboratory setting [33].
There was no information about the biomechanical properties of
Endobutton assisted repairs without a secondary fixation device.
Our results showed higher resistance to failure than the Krackow
technique and support the biomechanical feasibility for the clinical
use of the Endobutton technique in acute ruptures.
The Krackow method was chosen as a comparison group in this
study because of its worldwide acceptance as a representative
method for tendon repairs. It is still a preferred technique as a
control in many biomechanical studies [34–39]. Although there
are various types of suture techniques used for tendon repairs
such as Kessler and Bunnell stitches, biomechanical superiority of
Krackow suture technique for Achilles tendon repairs has been
demonstrated in previous studies [40,41]. In a recent paper,
Maquirriain also recommended the Krackow method to reduce
tendon lengthening during Achilles tendon repair [41], which is
has been shown to be essential for obtaining better outcomes [42].
The superior failure force of our technique may allow the
opportunity for early rehabilitation with less gapping at the
repair site. The other advantage is its applicability in minimally
invasive repair.
Acute Achilles tendon rupture is most commonly managed with
open surgical repair even with its relatively high rate of
complications [17,42–45]. However in last decade, minimally
invasive treatment of Achilles tendon ruptures has become an
increasingly popular technique with orthopaedic surgeons
[9,13,14,46,47]. Cretnik et al. published comparable functional
outcomes of percutaneous suturing to open repair, with a
significantly lower rate of complications [17]. McClelland and
Maffulli recommended percutaneous repair as a safe and reliable
method in patients with lower demand because of its slightly
higher incidence of re-rupture [48]. Subsequently Carmont and
Maffulli established a modified minimally invasive suture tech-
nique with a lower complication and rerupture rates [16].
 G. Huri et al. / Foot and Ankle Surgery 19 (2013) 261–266
However, Huffard et al. described disadvantages of percutaneous
repairs including the difficulty of achieving appropriate tension at
the repair site without visualizing the rupture ends [49]. To
address this issue, Doral et al. proposed endoscopically assisted
percutaneous repair and reported satisfactory results without
rerupture [9]. In a recent study Henriquez et al. found no
difference between open and percutaneous repairs after mean of
18 months [50]. In a recent study Ortiz et al. compared the
biomechanical properties of four different minimal invasive suture
techniques for repair of the Achilles tendon ruptures in bovine
model. They demonstrated the superiority of the modified triple-
strand Dresden repair technique (mean load to failure 675 N) over
double-strand technique (mean load to failure 327.8 N) [22].
However in case of the rupture with shredded distal part, we can
guess that, both of these repair techniques may not provide
adequate purchase to maintain the resistance against distraction
during early range of motion. The transosseous fixation of the
endobutton technique may provide a stronger initial construct
when the distal stump is compromised, but would need to be
studied further. Therefore, it is obvious that there is still no
consensus about the best repair technique for Achilles tendon
rupture, which has a tenuous distal stump [41,51–54].
The most common site for Achilles tendon rupture is 2–6 cm
from the calcaneal insertion due to a smaller cross sectional area
and a relatively poor blood supply compared to the rest of the
tendon [55,56]. In acute traumatic ruptures, it is frequently
difficult to achieve a firm and reliable grasp of the distal tendon
stump because of either shredding or inadequate length. Our
described transosseous technique can considered providing
stronger fixation than primary suture repair based on our study
result. Moreover, quality of the distal tendon remnant is not as
important as in the other techniques to provide a strong repair and
allow early range of motion.
There are some limitations of our study. First, our study uses
ovine tendon. The calcaneus in the ovine never touches the ground
[57]. Therefore generalizing the results from animal studies to
humans is not always straightforward. The histology of the ovine
Achilles is different from the human Achilles and the rupture site
may also be in a different location [58–60]. Our model used a clean
laceration as opposed to the ‘‘mop ends’’ typically seen in acute
Achilles tendon ruptures. A surgical transection of the tendon
produces a more consistent stump to test across specimens. An
inconsistent stump was anticipated to detract from our ability to
comment on the strength of the suture configuration alone and
introduce variability into the model, especially in the Krackow
group. Another potential limitation of our technique is the possible
need for a second operation to remove a symptomatic implant if it
is placed where the plantar fat pad is thin. This may lead to
increased total cost, both because of potential for reoperation and
because of the cost of the implant itself. It may also be difficult to
tension the repair appropriately if this technique is attempted
through a less invasive approach. In regards to the testing model,
cyclic loading measurements were not obtained in this study and
may be useful when comparing the two constructs. Further human
cadaveric and clinical studies are necessary to enhance our
knowledge regarding this technique.
Strengths of the study include adequate power to detect a
difference among the study groups. All other variables were kept as
consistent as possible, including age of the donor sheep, tendon
size, and a single surgeon performing the repairs.
Based on our study results, using the Endobutton-assisted
modified Bunnell technique has three advantages. (1) It can
provide stronger fixation than conventional techniques even if
there is poor quality tendon at the distal part of rupture. (2)
Concerning its higher resistance force against rupture, our
technique can allow early range of motion. (3) It can be easily
265
applied to techniques used in minimally invasive and percutane-
ous methods.
Conflict of interest
The authors have no conflict of interest.
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