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Percutaneous Achilles tendon repair using a simplified dual zig-zag technique with monofilament suture: A technical note and mid-term outcomes
*Corresponding author: Billy Leoprayogo, Department of Emergency Medicine, Fatima Hospital Ketapang, Ketapang Regency, Indonesia. billyleoprayogo@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Leoprayogo B, Guatama A. Percutaneous Achilles tendon repair using a simplified dual zig-zag technique with monofilament suture: A technical note and mid-term outcomes. J Musculoskelet Surg Res. 2025;9:515-21. doi: 10.25259/JMSR_267_2025
Abstract
Achilles tendon rupture (ATR) significantly impairs mobility and quality of life. Percutaneous repair offers minimal soft tissue trauma with satisfactory outcomes; however, many techniques require specialized tools and sutures, often unavailable in resource-limited settings. This study aimed to present a simplified dual zig-zag percutaneous repair technique using generic monofilament suture and report the mid-term outcomes. Patients with ATR treated at our institution between 2022 and 2024 who underwent a simplified percutaneous repair using a dual zig-zag configuration with monofilament sutures were included. Patient characteristics, cause of injury and timing, surgical duration, return to daily activities and sports, calf circumference differences, and complications were recorded retrospectively. The American Orthopaedic Foot & Ankle Society (AOFAS) score was used to evaluate functional outcome at 6-month follow-up. Ten patients (mean age, 31.0 ± 8.47 years) were included. All injuries were sport-related. The mean time from injury to surgery was 3.4 ± 1.43 days, with a surgical duration of 25.2 ± 5.19 minutes. All patients returned to daily activity within 6.5 ± 1.69 weeks and to recreational sports at 12.14 ± 1.46 weeks. Calf circumference difference between the affected and the healthy limb was -1.23 ± 1.43 cm. There were no re-ruptures, infections, or sural nerve injury. AOFAS score improved from 54.7 ± 11.52 preoperatively to 94.3 ± 3.69 (P < 0.001) at final follow-up. This simplified percutaneous repair technique utilizing monofilament suture is simple, safe, and effective. It provides reliable tendon healing without requiring specialized instruments, making it particularly suitable for resource-limited settings.
Keywords
Achilles tendon
Minimally invasive surgery
Rupture
Suture techniques
Tendon injury
INTRODUCTION
Despite being the largest tendon in the human body, Achilles tendon rupture (ATR) is a common occurrence, accounting for approximately 10.7% of all tendon injuries.[1] ATR most commonly occurs during sports, both recreational and competitive.[2] Tennis, basketball, soccer, and badminton are common sports associated with ATR.[3] This injury significantly impairs mobility, daily function, and overall quality of life. Many patients are unable to return to their pre-injury level of performance.[4]
The management approach for ATR, whether surgical or conservative, remains a subject of ongoing debate. However, recent studies suggest that surgical management has a superior outcome compared to conservative management.[5,6] Conservative treatment, such as cast immobilization, is associated with high re-rupture rates.[7] Surgical treatments for ATR repair can be broadly categorized as open, mini-open, and percutaneous approaches. Open repair surgery resulted in strong fixation and a lower risk of re-rupture but carries higher rates of wound healing complications and infections.[5] To minimize these risks, mini-open surgery was developed. This technique utilizes a suture-guiding device, allowing a less invasive approach, precise tendon approximation, and a reduced risk of sural nerve injury.[8] However, such devices are often unavailable in resource-limited areas.
Percutaneous surgery was initially introduced by Ma-Griffith and has been modified extensively over the years to improve its safety and efficacy.[9] Our simplified percutaneous dual zig-zag technique uses readily available materials, ensuring strong tendon fixation to promote effective healing. This technique aims to strike a balance between ease of application, mechanical reliability, and favorable clinical outcomes.
This technical note describes the surgical steps and reports the mid-term clinical outcomes of patients treated with this technique.
OPERATIVE TECHNIQUE
Patients selections
This single-center retrospective series enrolled patients with acute ATR and treated with the simplified percutaneous dual zig-zag technique at our institution between 2022 and 2024.
Inclusion criteria were a clinical diagnosis of posterior heel pain, limited or absent plantar flexion, history of trauma, palpable tendon defect, and a positive Thompson test. Patients with delayed presentation (>2 weeks from injury), associated bony avulsion, or other comorbidities were excluded.
Patient data recorded include age, sex, body mass index (BMI), affected limb, cause and timing of injury, duration of surgery, length of stay, time to return to activity and sports, calf circumference difference at follow-up, and any complications. The American Orthopedic Foot and Ankle Society (AOFAS) score was used to evaluate the functional outcome both preoperatively and at the 6-month follow-up.
Data analysis
Collected data were analyzed using the Statistical Package for the Social Sciences software (IBM Corp., Version 22.0, NY, USA). Descriptive analysis was reported using means ± standard deviations or frequencies with percentages. The Shapiro-Wilk test was used to assess the normality of the distribution. Comparative analysis was conducted using a paired t-test. P < 0.05 was considered statistically significant.
Surgical technique
All procedures were performed under spinal anesthesia, and the patients were placed in the prone position. The Achilles tendon was palpated and marked [Figure 1]. The surgical area was cleansed with chlorhexidine antiseptic solution and draped in a sterile manner.
- Marking of (a) skin incision points and (b) tendon margins.
Two non-absorbable, monofilament polyvinylidene sutures (T-lene 1, Triton Manufacturers, Indonesia) were prepared. Each suture’s needle was straightened, and the free ends were tied together to form a single strand with straight needles at each end [Figure 2].
- Suture preparation. (a) Two non-absorbable monofilament sutures. (b) Needles were flattened, and suture ends were tied. (c) The final suture becomes a single strand with flat needles at both ends.
Six 1-cm longitudinal skin stab incisions were made:
Two stab incisions at 5 cm proximal to the palpable defect (points A and B).
Two stab incisions at the level of the palpated defect (points C and D).
Two stab incisions 5 cm distal to the palpable defect (points E and F).
All incisions were made 1 cm medially and laterally to the tendon border, forming a rectangular pattern. Blunt dissection was performed for each incision using forceps or clamps to reduce the risk of damaging the sural nerve.
One needle of the modified suture was passed transversely through the proximal incisions (points A to B), then obliquely down to the middle incisions (points B to C) and distal incisions (points C to F), and passed transversely (points F to E). The second end passed in the same pattern.
Cut the strands, leaving enough length for knotting. Prepare the modified suture once again, and repeat the process in a mirrored fashion, starting at mark B and ending at mark F. This created a dual zig-zag suture configuration across the tendon stumps [Figure 3]. The sequence can be simplified as:
- Schematic illustration of suture passing sequence. (a) A-B-C-F-E sequence, (b) B-A-D-E-F sequence. (c) Final dual zig-zag configuration.
A → B → C → F → E → Repeat the pattern for the second end, then
B → A → D →E → F → Repeat the pattern for the second end.
Make sure to pass through the tendon stumps as if passing through the needle. The construct was complete with both ends at the distal incisions to be tied. In a fully plantar-flexed position, both suture ends were tightened and tied at the distal stumps to secure the construct. The knots were buried under the skin incisions [Figure 4].
- Surgical photograph of a patient. (a) The first needle was passed transversely through the proximal incisions. (b and c) obliquely to the middle and distal incisions. (d) Repeat the pattern with the second needle, with both suture ends at the distal incision. (e and f) Mirrored pattern for the other side. (g) Final construct with both knots buried under the skin incisions.
This construct was then tested with passive dorsiflexion and plantar flexion under considerable forces. An anterior splint with the ankle in a fully plantar-flexed position was applied to complete the procedure.
Post-operative protocol
Patients were discharged the day after surgery, once they had fully recovered from anesthesia. Patients were instructed to remain non-weight-bearing on the operated limb for 4 weeks, using crutches for ambulation during this period. Patients were scheduled for follow-up at 2, 4, and 6 weeks postoperatively. At the 4-week follow-up, the anterior cast was removed, and patients were allowed to start partial weight-bearing with crutches and practice active ankle flexion as tolerated. No walking boot, specialized footwear, or heel lift was used. Patients were expected to achieve full weight-bearing without assistive devices by the 6-week follow-up [Figure 5]. Functional progress, complications, and complaints were noted at each follow-up.
- Clinical outcome of the patient at 6 months follow-up: (a) Minimal scarring and (b) ability to stand on the tiptoes of both lower limbs.
Results
Patient’s characteristics
This study included 10 patients (seven males and three females) with a mean age of 31.0 years (range, 19–45 years) and a normal to overweight BMI (21.96 ± 1.49 kg/m2). All injuries were sport-related. The onset was acute, with a time from injury to surgery of 3.4 ± 1.43 days (1–6 days). Patient characteristics in this study are reported in Table 1.
| Characteristics | Results (frequency) or (mean±SD) |
|---|---|
| Age (years) | 31 (range, 19–45) |
| Sex (n) | |
| Male/Female | 7/3 |
| BMI (kg/m2) | 21.96 ± 1.49 |
| Sides (n) | |
| Left/right | 5/5 |
| Cause of injury (n) | |
| Badminton | 5 |
| Soccer | 3 |
| Basketball | 1 |
| Other recreational sports | 1 |
| Time to surgery (days) | 3.4±1.43 (range, 1–6) |
BMI: Body mass index, SD: Standard deviation
Surgical outcomes
The mean surgical duration was 25.2 ± 5.19 min. All patients returned to their daily activities within 6.5 ± 1.69 weeks and resumed recreational sports at 12.14 ± 1.46 weeks after surgery. Eight patients reported that they achieved their pre-injury performance in their recreational sport, while two patients did so at a reduced level of intensity.
The mean calf circumference differences between the affected and healthy limb were −1.23 ± 1.43 cm. The mean AOFAS score was improved significantly from 54 ± 11.52 preoperatively to 94.3 ± 3.69 postoperatively at 6 months follow-up (P = 0.0003).
All incisions healed with minimal scarring [Figure 5]. There were no cases of sural nerve injury, infections, or re-rupture observed in our patients. Surgical outcomes and complications of this technique are summarized in Table 2 and Table 3.
| Surgical outcomes | Results (Mean±SD) or (%) |
|---|---|
| Surgical duration (min) | 25.2±5.19 |
| Return to activity (weeks) | 6.5±1.69 |
| Return to sport exercise (weeks) | 12.14±1.46 |
| Calf circumferences differences (cm) | −1.23±1.43 |
| Complications | |
| Re-rupture | 0 |
| Infections | 0 |
| Sural nerve injury | 0 |
SD: Standard deviation
| AOFAS score | Preoperative | 6 months follow-up | P-value |
|---|---|---|---|
| ≥95 (excellent) | 0 | 7 | - |
| 75–94 (good) | 1 | 3 | - |
| 51–74 (fair) | 6 | 0 | - |
| ≤50 (poor) | 3 | 0 | - |
| Mean±SD (range) | 54±11.52 (35–75) | 94.3±3.69 (87–99) | <0.001 |
AOFAS: The American orthopedic foot and ankle society, SD: Standard deviation
DISCUSSION
In active sports, athletes with ATR often undergo surgery to prevent muscle atrophy, improve ankle range of motion, and facilitate a return to their sport.[5] Surgical techniques have undergone rapid improvement over the years, particularly in percutaneous repair techniques, as described by Ma-Griffith in 1997, and more recently by Maffulli et al.[9] Percutaneous repair technique proved to have a lower infection rate, better mobility, and shorter surgical time compared to open and mini-open repair techniques; however, the risk of sural nerve injury was higher due to limited visualization of the tendon compared to the open repair technique.[10] Modern percutaneous or mini-open guided devices such as the Achillon® System (IntegraTM, LifeScience), the Percutaneous Achilles repair system (PARS, Arthrex®), the Channel-assisted minimally invasive repair (CAMIR) device, and the Dresden instrument have been developed to overcome these complications.[11,12] However, these devices made the repair relatively more complex, with longer operating times, and most likely to be unavailable in areas with limited resources.[13]
This study demonstrated that our simplified Maffulli’s percutaneous repair technique, using a generic monofilament suture, is a safe, effective, and low-cost method for managing acute ATR, with satisfactory mid-term outcomes. Patients in our studies achieved tendon healing, indicating that this technique provides adequate approximation and secure fixation of tendon stumps while respecting biological principles.
Hsu et al. reported that 237 out of 270 (88%) patients treated with either PARS or open surgery achieved return to activity within 5 months.[14] Our technique achieved a faster return to activity, with an average of 6.5 ± 1.69 weeks and 12.14 ± 1.46 weeks for sports exercise. However, Ko et al. reported a faster return to daily activity, averaging 45.5 days, but a longer return to sports exercise, which was 147.5 days, using their technique.[15] Wang et al. showed that the mean time to return to exercise for patients treated with percutaneous repair techniques ranged from 21.7 to 31.0 weeks.[16]
In our study, the difference in calf circumference between the affected and healthy side was 1.23 ± 1.43 cm. This result aligns with Wang et al., who reported a difference of 2.34 + 1.45 cm at 12 months following percutaneous repair.[16] However, the clinical significance of calf size differences on functional outcomes remains uncertain. It has been suggested that atrophy of the soleus muscle may be compensated by flexor hallucis longus and deep flexor muscles hypertrophy, as previous studies have shown no association between calf circumference and heel-rise index.[16,17]
Post-operative AOFAS score in our study reached 94.3 ± 3.69 at follow-up. It was a satisfactory achievement as it was comparable to other techniques. Calder and Saxby obtained a satisfactory AOFAS score of 98.4 points following repair with the Achillon system.[18] Chen et al. reported an average AOFAS score of 90.5 points at 1-year follow-up after using the mini-open technique with the CAMIR device.[12] Li et al. reported AOFAS scores of 95.0 ± 3.8 and 92.3 ± 5.3 for mini-open and percutaneous repair techniques, respectively.[13]
Surgical time is a relevant variable, as prolonged surgery time was associated with a higher risk of surgical site infection.[19] Our simplified technique had a mean surgery duration of 14.9 ± 4.48 min, and no infection was observed in our patients. A recent meta-analysis showed that the mean surgical times for open repair and minimally invasive surgery were 51.0 and 29.7 min, respectively.[10] Li et al. reported averages of 27.7 ± 4.3 and 23.1 ± 5.2 min for mini-open and percutaneous repair, respectively.[13]
The complication rate was also favorable in percutaneous repair, as previous reports, which compared it with open or mini-open surgery, showed significantly lower risk of infections and re-rupture. However, the percutaneous repair technique was associated with a higher risk of sural nerve injury.[10] The re-rupture rate ranged from 3.5% to 4.3% in patients treated surgically, compared to 8.8–9.7% in patients treated conservatively. However, no significant difference in re-rupture rates between percutaneous repair and other surgical techniques.[20] In our study, no re-ruptures, infections, or sural nerve injuries occurred in our patients during the last follow-up period.
The original Maffulli’s percutaneous cruciate technique used an absorbable braided suture.[9] Mechanical studies showed that absorbable suture had a lower load-to-failure property compared with non-absorbable suture. However, the clinical re-rupture rate across both suture types was low, with no significant difference between groups.[21] Braided suture materials are associated with an increased risk of postoperative infection due to the multifilamentous strands, which increase the surface area for bacterial adherence.[22] Our technique utilized a non-absorbable monofilament material, as it was widely available and comparable in terms of re-rupture and infection rates to absorbable braided materials.
The nature of our simplified percutaneous repair technique benefits from low soft-tissue insult, reducing the risk of infection, facilitates faster tendon healing, and results in smaller scars. Despite using a simple material, the repair construct demonstrated to be a strong, durable, and reliable method to achieve tendon healing with a low complication rate.
Limitations in this study were a small sample size, a single center, the absence of control groups, and a retrospective design. In addition, the short- to mid-term follow-up period limits our ability to evaluate long-term outcomes, such as degenerative changes or tendon elongation. Therefore, future multicenter, randomized controlled trials with a longer follow-up period and larger sample size are needed.
CONCLUSION
This technique is simple, effective, and safe for acute Achilles tendon repair, with high reproducibility due to the use of commonly available materials. It is a reliable technique that does not require specialized devices or expensive materials, especially in areas with limited resources.
Recommendations:
Further study with a larger sample size, a longer follow-up period, and comparative designs is encouraged to validate these findings.
Authors’ contributions:
BL contributed to the study design, collected and organized data, performed statistical analysis, and prepared the manuscript. AG contributed to the study concepts, data acquisition, performing surgery, manuscript editing, and review. All authors have reviewed and approved the final draft and are responsible for the manuscript’s content.
Ethical approval:
The Institutional Review Board reviewed the study design and granted a waiver of ethical approval, as it involved retrospective data analysis, in accordance with our institution’s protocol.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given their consent for their images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Conflicts of interest:
There are no conflicting relationships or activities.
Financial support and sponsorship: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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