All right, well thank you very much. I'm sorry we're a little bit behind, but unfortunately with Norm and I, I don't know if that's going to get any better, but I'm going to try to fly through this. So updated disclosures that's on the website, no royalties that are relevant to this as far as Achilles. So when we look at non-insertional rupture, we realize and understand that this is a devastating lower extremity injury to athletes. And when we look at classic operative and classic non-operative treatment, operatives favor due to the increased risk of re-rupture, but that comes at a cost. And why are we still talking about this? It's because when we look at this, and whether it's the Cochrane Review or some of the other studies, we understand that even in looking at multi-center studies, open operative repair significantly reduces the risk of re-rupture, but significantly increases the risk of complications such as infection with long incisions. And so the idea even with this is that, well, if we can do this less invasively, it may be better, but there haven't been a ton of studies that really look at this. And we understand that complications are a problem. This is from Andy Hsu's article talking about this. When you get an extensile incision with this problem in the back of the heel and the lower leg, this is high dollar real estate because it's very difficult once you get a bad wound to be able to cover it. So how could non-operative treatment have any appeal in any of our athletes? Because we understand that this is not just a poor health, poor access issue. We know that with the Indianapolis Colts' Robert Mathis. We also understand this with the Philadelphia Phillies' Ryan Howard. I mean, these are career-altering types of issues when they develop. What about when we look at historical function and return to sports after this? It's a bleak prognosis. Whether that's from Celine Preak's article in 2009 that's constantly talked about in the media, we understood that a third of the players never returned, and of those who did, they did not perform as well. That's true also in the NBA, not a whole lot different, where 40 percent almost never really returned, and of the ones that did, it was very difficult for them to continue a long-term career after this. So is functional non-operative treatment as it's been proposed, though, is that really the answer for our athletes? You've got to really understand, though, what the question that was being addressed and that was answered and whether or not it's appropriate. If we look at that Willits article, which is the most commonly referenced one for functional non-operative treatment, this was powered simply to look at re-rupture, not at function. So they showed differences at strength at one and two years, but it was of unknown significance because they didn't power to look at it. The same is true of the Sorosanoe article in JBS in 2012, where they understood that surgical patients return to function, return to work faster, and that randomized controlled trials needed to understand these less invasive techniques to this functional non-operative treatment. This is now the latest buzz as far as functional non-operative treatment from a study over overseas, looking at, you know, got a ton of press, whether it's the U.S. News and World Report here. If we look at this in this New England Journal of Medicine article, though, what they proposed is that non-operative treatment, open repair, and minimally invasive surgery led to similar health status at 12 months. And so this is based out of Norway. The problem with this is that, first off, any patient not seen within 72 hours and placed in a quinus position was excluded. Second thing, as far as their re-rupture rate, it was 10 times likely to re-rupture with the non-operative compared to the operative. And with the minimally invasive technique that they used, they used this Dresden hook technique, which had complications associated with it. And then also, then more importantly, when they did the operative technique at time zero in the OR, they tensioned it to the same as the opposite side. As we'll talk about later, that's a death knell as far as function, because everything's going to stretch out. This is the Dresden hook technique, you know, obviously very simple, not very costly, but you can imagine how several nerve issues could happen with that. So what's the real story? If we look at the Lanto et al. article in 2016 in AJSM, surgery restored calf muscle strength earlier over the entire range of motion, up to 24% at six months, and it persisted even at 18. And so we have to understand that it's not simply infections, but a loss of power is also a complication, particularly for high-level athletes. So as percutaneous for many opened the answer, is it strong enough to safely perform aggressive early functional rehab, and are the complications low? If we look at this, this is not something brand new. The first to describe this was Mon Griffith in 77. There were mixed results since that initial study, but this is how it was done. Three separate transverse incisions using a device to be able to pass that deep to the peritoneum. And then when we look at this, you know, Dr. Bradley's obviously in the back, but this is an initial study that he did with Thiboney. And when they initially looked at this, it was 15 open versus 12 percutaneous. They had two re-ruptures in that percutaneous group compared to zero in the open. And so their conclusion at that time was, look, in a high-level athlete, we can't afford a re-rupture, therefore treat them all open. The Achillon was the first percutaneous system in the U.S., but these were transverse, non-locking sutures. The concerns was it was a disposable, flimsy device, and single transverse sutures would frequently miss the tendon. Despite that, even with some of the studies that have been shown, there are less complications and no significant difference in outcome scores. What about this percutaneous Achilles repair system? It's an improved, more stiff anatomic jig. It creates locked instead of transverse sutures. But how do you manage the people that are a little bit delayed at four to five weeks? In short, this is simply just a way of creating a non-locked or locked suture percutaneously and subperitoneum through a tendon. When we look at the mechanics, is it strong enough? This is an HSS study looking at this compared to the Achillon device, and what they showed is greater load to failure and more resistance when you're able to get that locked construct compared to a simple transverse, non-locked loop, and that you're able to resist the forces needed for rehab. What about when we look at mini-open compared to open outcomes? Even a modified Monn-Griffith technique done by Maffulli showed an average return to sport at around five months and 100% return to that function with minimal complications. Same is true with the initial nine athletes that Bob Anderson had looked at in the NFL with no re-ruptures and the fastest athlete that was able to return, and we'll talk about a little bit later at five and a half months. What about general population applicability? Andy Hsu did a great study, a single institution study looking at over 270 patients with 6% fewer complications and near 100% return to baseline function at five months. These are the options. You can either do it suture to suture or anchor it down into the heel with anchors. So the key thoughts about this is the Achilles wants to heal. The understanding of the re-rupture considerations is that if you minimize soft tissue disruption and you tension it, it will heal. The question is, can you maintain that tension throughout the rehab process? We understand that the skin is sensitive and less is more. You've got to be meticulous about the skin. I routinely close the peritoneum separate from the deep dermis and the dermis, but if you place this incision in skin lines, this is how it wants to heal. Before we've even done any type of deep dermal stitch, that's then with some simple glue after we've done a deep dermal stitch, that's at a week, that's at two, that's at six, and then that's at three months. Tissue back here wants to heal. We just need to not try to disrupt it as much. The other issue is the tensioning that we talked about that was in that Norway study. So plantar flexion tensioning do not match the other side. All of these stretch out. That's not a failure of sutures. That's as this construct continues to elongate as someone continues to walk. It's not just simply a loss of power, but a lack of tension is a complication of this as well as it relates to function. This is true in the AJSM article that looked at different rehab protocols, understanding that non-weight bearing without motion, non-weight bearing with motion, and immediate partial weight bearing, every single one of those constructs stretched. So maximally tension it because it's going to stretch regardless of whether you think it will or not. As far as examination, any prior insertional complaints on physical exam, do they have tenderness to palpation and or prominence at the insertion? Obviously a loss of resting plantar flexion tension when you're prone and with that knee at 90 degrees that is asymmetric to the opposite side. I don't care what the MRI report or anything else says, that is clear elongation of that construct and they're going to have issues. Imaging, I always get a lateral x-ray for issues such as you see right there because what you have to understand is that these may be complex and you may be in a situation such as this where it's a complex insertional rupture where there's maintained tissue but also a non-insertional disruption. Very briefly, as far as insertional Achilles treatment, mainstay of treatment is conservative for insertional tendinopathy. I do not think there is ever an indication for an insertional rupture being treated non-operatively. But when we look at these athletes, historically, at least 25 to 50% if they've had chronic insertional tendinopathy are going to need some type of surgery, whether it comes from a rupture or persistent pain and inability to truly perform well. Anecdotally, we've seen this even higher in the elite athletes. The issue here, why does insertional tendinopathy matter? Because looking at Achilles rupture, secondary insertional disease, it's a significantly increased return to sport pathway. So if you can intervene when they've had symptoms for longer than six to nine months, that can be an indication when the appropriate conservative measures have failed. What about accelerated rehab? Actually, motion-accelerated rehab is critical to that recovery process. It promotes tendon healing. There's less scarring and less disease to atrophy and certainly the use of blood flow restriction as it relates to this, even if it's not elongating that tendon, but getting the muscle tendon unit firing can be very beneficial. I progressively wean these folks from a boot to a shoe at 10 weeks. You can begin protected running activity with some type of gravity-altering type of construct and begin on-field and court running at around four months when they're strong enough. This was an operative techniques and sports medicine article that Bob and I did on this that's a great reference if you need one to be able to look at some of these kind of considerations. But if we look, I mean, this is not something that's simply just hypothetical. Certainly Terrell Suggs, when he tore his first Achilles, there were a lot of naysayers as to what was going to happen when this happened in the off-season training activities. But the reality was he was able to come back and participate in their playoff run that season. Unfortunately for him, he then had an opposite-sided injury that then, once again, the naysayers came out, but he was still able to come back from that, once again, with a mini-open type of procedure and was able to earn Pro Bowl honors after that. The question is, is that an Adrian Peterson one-off? Derek Johnson's no different. Ruptured one side, was able to come back, then ruptured the opposite side. Once again, both treated mini-open, was able to do it. And it's not simply even just American football. This is also soccer as well. This is someone who was able to come back from a less invasive procedure and become a Defender of the Year not once, but twice after that, and numerous other athletes. So my opinion is that standard open treatment will fall out of favor because of the complication risk. And as we talked about some of the legality and litigation issues yesterday, we've got to try to minimize complications. Complications can happen at any point, but this is a tough, tough injury when you get a complication in the back. You've got to tension them, you have to have less soft tissue disruption, and really kind of have a key rehab. Because rehab for this is just as critical, if not more important, than the surgery itself. And early studies certainly show that minimally invasive can be very successful for these folks. Thank you very much. Thank you.

Achilles tendon ruptures

treatment options

operative repair

non-operative treatment

percutaneous Achilles repair system