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Abstract

Introduction

Anatomy of the Achilles Tendon

The Achilles tendon is one of the strongest and most relied-upon structures in the human body. Connecting the Gastrocnemius and Soleus muscles of the calf to the Calcaneus of the heel, it is the primary plantar flexor of the ankle [1]. Almost any lower body movement such as walking, running, or jumping requires the actions of the Achilles tendon.

 

Mechanisms of Acute Achilles Tendon Ruptures

The Achilles tendon is most susceptible to rupture 3-6 cm proximal to its insertion point at the calcaneus [2]. Additionally, incidence rates are higher in the young male and geriatric male populations compared to other groups. The primary mechanisms causing the most stress to the tendon are pushing off with the forefoot while the knee is extended and sudden dorsiflexion of the ankle, especially if the motion is fierce while the foot is plantarflexed [2]. Since athletes repeatedly perform these movements and impose significant stress on the tendon during practice and competition, evidence has shown ruptures predominantly occur among this group.

Despite understanding the primary mechanisms behind the tendon rupturing, researchers and physicians are concerned with factors contributing to the deterioration of the Achilles tendon. Theories commonly considered include athletes returning to activity following an extended absence [2]. Upon returning to activity, the athlete’s technique may differ from how the ankle was typically used before their absence, which can cause unusual stress to the tendon. An example of this could include a football player returning from knee surgery who is in the beginning stages of walking and running again.

 

Pharmacological Contributions to Achilles Tendon Ruptures

Additionally, other theories causing degeneration of the Achilles tendon include pharmacological treatments such as quinolones and corticosteroids. A systematic review to determine the relationship between quinolone use and Achilles tendon ruptures indicated an increased risk with an odds ratio (OR) of 2.52, Confidence Interval (CI) of 1.81-3.52, and p < .001 [3]. Quinolones, in addition to being an effective antibiotic, reduce the transcription of decorin, a proteoglycan essential for maintaining the structural integrity of cartilage, skin, and tendons [4].

Corticosteroids, a commonly used anti-inflammatory medication, also contribute to tendon rupture due to impaired inflammatory and healing properties essential to maintaining structural integrity. Inflammatory cytokines released following injury to tendons stimulate tendon cell proliferation; when this process is impaired, tendons are damaged without restorative mechanisms for healing [5].

 

Standard Achilles Tendon Rupture Surgical Techniques

Surgical and percutaneous techniques exist for Achilles tendon rupture repair. Currently, the traditional surgical technique is the Open Achilles Tendon Repair technique in which the proximal and distal ends of the ruptured Achilles are sewn together utilizing a modified locking Bunnel stitch [6,7]. This technique should still be prioritized in patients who experience severe or chronic tendon damage, wide tendon ruptures, or have poor bone mineralization preventing sufficient bone anchoring with the speedbridge technique [6, 7, 8]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Figure 1: Open Achilles Tendon Repair technique utilizing a modified locking Bunnel stitch [9]

 

A percutaneous technique provides patients with an alternative to open surgery while providing adequate tendon repair. With the percutaneous technique, small incisions are made on the posterior calf, allowing physicians to insert instruments and materials to repair the damaged tendon internally utilizing the Arthrex PARS Guide, an instrument surgeons use to conduct their repair of the tendon [10]. Surgeons can also utilize ultrasound guidance while performing this technique.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Figure 2: Percutaneous Repair Technique via Arthrex PARS Guide [10]

 

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SpeedBridge Technique as an Alternative

Alternative techniques for Achilles tendon repair are being explored due to current techniques requiring an extensive rehabilitation process for sometimes more than a year. One such technique is the SpeedBridge technique in which the damaged tendon is repaired using fiber tape anchored into the calcaneus [7]. In doing so, the tendon is repaired in a way that increases strength, stability, and durability when compared to the standard suturing technique [7]. As a result, patients can perform weight-bearing exercises earlier in the healing process, reducing the recovery duration [7]. Because of these advantages, the Speedbridge technique is being explored to become the modernized standard for Achilles tendon repairs.

 

Surgical Technique [7,8,11]

1. Place the patient in the prone position and apply a tourniquet to the proximal thigh

2. Make a 6-8 cm midline, longitudinal incision, exposing the paratenon, extending from the superior posterior edge of the calcaneus

3. Arrange the 2 tendon flaps laterally and anteriorly, exposing the Haglund's tubercle of the calcaneus

4. Using a saw and osteotome, remove Haglund's tubercle [Figure 3]

5. Approximately 1 cm proximal to the Achilles insertion point, drill a 4.75mm SwiveLock anchor into the lateral posterior calcaneus to the level of the shoulder stop on the drill guide

6. Insert the 4.75mm SwiveLock loaded with fiber tape into the anchor body until flush with the bone [Figure 4]

7. Repeat Steps 5 and 6 on the medial posterior surface of the calcaneus

8. Pass the needle attached to the fiber tape on the lateral side through the lateral tendon flap and pull the fiber tape through; repeat using the medial fiber tape, pulling it through the medial tendon flap [Figure 5]

9. Distal to the Achilles tendon insertion, drill a lateral and medial socket to the shoulder stop on the drill guide

10. Using one fiber tape tale from both the lateral and medial SwiveLock, adjust for tension, and insert the tails into the lateral socket until the anchor body is flush with the bone; repeat this step for the medial socket [Figure 6]

11. Place sutures along the paratenon and close the wound

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Discussion

Achilles tendinopathy, rupture, Haglund's tubercle deformities, and other biomechanical vulnerabilities have burdened athletes, overweight populations, and aging individuals [13]. Specifically, the SpeedBridge technique has garnered interest due to its minimally invasive nature and better results for patients compared to traditional open Achilles repair and/or nonoperative alternatives [14].

 

Quicker Recovery Period

A retrospective study on 41 patients by Sattele et. al. showed that Percutaneous Achilles Repair System (PARS) with Midsubstance SpeedBridge allowed for a quicker recovery duration (119.2 +/- 44.0 days) compared to the traditional open surgical approach (169.4 +/- 41.6 days, P = 0.019) [15]. Furthermore, some studies claim the Speedbridge technique can further improve recovery times by incorporating an endoscopic approach versus open techniques. In a study with 89 patients, Lopes et al. found that those who underwent an endoscopic Speedbridge technique reported significantly better Victorian Institute of Sport Assessment - Achilles tendinopathy (VISA-A) questionnaire scores (p < 0.001) and European Foot & Ankle Society (EFAS) scores in both daily life (p < 0.001) and sports activity (p < 0.022) when assessed 3 months after procedure. They also found shoe discomfort at 6 months was less prominent in those who went through the endoscopic variant (3.7%, P=0.099) when compared to open surgery [16].

 

Improved Biomechanical Strength

A stress-loading experiment on 27 ankle cadavers by Melcher et. al. showed that the Achilles Midsubstance SpeedBridge repaired tendon elongated less than other common surgical interventions, PARS (P = 0.102), and the Dresdner instrument (P = 0.0006). The Midsubstance SpeedBridge cadavers also survived more cycles of cyclic loading from 20 to 100N (538 +/- 208) compared to the others in the study [17].

 

Reduced postoperative complications

Deng et. al. explored eight randomized controlled studies and 762 patients with an Achilles tendon rupture and concluded a 3.7% re-rupture rate in those following surgical intervention compared to a 9.8% re-rupture rate in nonoperative treatment (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p = .001) [14]. Post-operative complications such as infections, post-operative pain, lack of strength and mobility, deep venous thrombosis, and nerve damage pose limitations as innovations continue. A literature review by Traina et al. analyzing 465 procedures showed that the average complication rate in surgery treating Achilles tendinopathy was 18.3% [18]. Although limited in scope due to the novelty of the SpeedBridge technique, few studies such as those by Fradet et. al. and Swaroop et. al. have shown that minimally invasive approaches such as the endoscopic variant have greatly reduced the risk of post-surgery complications [9, 19].

 

Limitations and Future Direction

Current limitations of the SpeedBridge Achilles repair should be addressed as innovation continues. The most common complication of Achilles tendon surgery techniques, including the SpeedBridge, is suture cut out at the suture-tendon interface [17]. As with other forms of surgery, SpeedBridge complications include superficial wound complications, deep venous thrombosis, scar adhesion, infection, and sural nerve injury were evident in several study subjects undergoing the SpeedBridge technique [20]. Earlier elongation with the first few loading cycles post-surgery was seen in some patients compared to those who underwent other forms of treatment [16, 17]. Stringent postoperative management is indicated to ensure proper rehabilitation and stability of the repaired Achilles tendon. Different variations of the SpeedBridge can also be employed which can greatly alter results, intentionally or unintentionally. For example, endoscopic vs. open, single-row vs double-row, varying extents of debridement, different lengths and widths of FiberTape, allograft vs. autograft, knotless vs. knot, and other surgical decisions can be employed based on institution, expertise, or necessity [10, 21, 22, 23, 24, 25]. Age, race, gender, metabolic and genetic disorders, nutrition, extent of injury, postoperative management, and concomitant medications must also be addressed before considering a treatment approach [26].

 

Conclusion

The SpeedBridge technique is a novel surgery method to approach Achilles tendinopathies and ruptures. The method involves distinct intricacies that allow for quicker weight-bearing activities and stronger biomechanical forces to support the tendon and the foot. Although nonoperative treatments are available, studies have shown the risk of re-rupture, length of recovery, personal preference, lack of traditional recovery within 6 months, improved biomechanical foot strength, lower complications, and improvements in mechanical constructs have led to many opting for the SpeedBridge method. Patients and practitioners must adhere to the proper pre- and postoperative guidelines and protocols to ensure the best outcomes.

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Appendices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Figure 4: Achilles Dissection with and without Haglund's Tubercle [10]

 

 

 

 

 

 

 

 

 

 

 

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Figure 5: SwiveLock loaded with fiber tape [10]

 

 

 

 

 

 

 

 

 

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Figure 6: Fiber tape passed through achilles tendon [10]

 

 

 

 

 

 

 

 

 

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Figure 7: Resultant SpeedBridge suture technique [10,12]

 

References

1. O'Brien M. The anatomy of the Achilles tendon. Foot Ankle Clin. 2005 Jun;10(2):225-38. doi: 10.1016/j.fcl.2005.01.011. PMID: 15922915.

2. Kauwe M. Acute Achilles tendon rupture: Clinical evaluation, conservative management, and early active rehabilitation. Clin Podiatr Med Surg. 2017 Apr;34(2):229-243. doi: 10.1016/j.cpm.2016.10.009. Epub 2017 Jan 29. PMID: 28257676.

3. Alves C, Mendes D, Marques FB. Fluoroquinolones and the risk of tendon injury: a systematic review and meta-analysis. Eur J Clin Pharmacol. 2019 Oct;75(10):1431-1443. doi: 10.1007/s00228-019-02713-1. Epub 2019 Jul 4. PMID: 31270563.

4. Chen S, Birk DE. Focus on Molecules: Decorin. Exp Eye Res. 2011;92(6):444-445. doi:10.1016/j.exer.2010.05.008.

5. Arvind V, Huang AH. Reparative and maladaptive inflammation in tendon healing. Front Bioeng Biotechnol. 2021;9:719047. doi:10.3389/fbioe.2021.719047.

6. Moore ML, Pollock JR, Karsen PJ, et al. Open Achilles tendon repair. JBJS Essent Surg Tech. 2023;13(1):e21.00054. doi:10.2106/JBJS.ST.21.00054.

7. Swaroop S, Dureja K, Vellaipandi V, Patnaik S. Speedbridge repair in degenerative achilles tear: A novel technique. Journal of Orthopaedic Case Reports. 2024;14(5):161-165. doi:10.13107/jocr.2024.v14.i05.4470

8. Hoffman J, Gupta S, Amesur A, Anthony T, Winder RP, Chan H, Hoang V. Achilles tendon rip-stop SpeedBridge repair. Arthroscopy Techniques. 2021;10(9):e2113-e2120. doi:10.1016/j.eats.2021.05.011​

9. ClinicalPub. Open repair of Achilles tendon rupture. Available at: https://clinicalpub.com/open-repair-of-achilles-tendon-rupture/. Accessed March 20, 2025.

10. Waldron P, Kennedy JG, Guss D, et al. Percutaneous Achilles repair with high-strength suture tape augmentation: a technical note. Arthrosc Tech. Published online 2024. Available at: https://www.arthroscopytechniques.org/article/S2212-6287%2824%2900538-3/fulltext. Accessed March 20, 2025.

11. Achilles SpeedBridge Repair - Arthrex. YouTube. Published December 12, 2016. Accessed March 18, 2025. https://www.youtube.com/watch?v=BCvGTmTEZcM.

12. Arthrex. Achilles SpeedBridge System. Available at: https://www.arthrex.com/resources/VID1-0463-EN/achilles-speedbridge-system. Accessed March 20, 2025.

13. Lopes R, Ngbilo C, Padiolleau G, Boniface O. Endoscopic speed bridge: A new treatment for insertional achilles tendinopathy. Orthopaedics & Traumatology: Surgery & Research. 2021;107(6):102854. doi:10.1016/j.otsr.2021.102854

14. Deng S, Sun Z, Zhang C, Chen G, Li J. Surgical treatment versus conservative management for acute Achilles tendon rupture: A systematic review and meta-analysis of randomized controlled trials. The Journal of Foot and Ankle Surgery. 2017;56(6):1236-1243. doi:10.1053/j.jfas.2017.05.036

15. Sattele LA, Worts PR, Guyer AJ. A comparison of minimally invasive Achilles repair techniques on functional outcome and failure rates. American Orthopaedic Foot & Ankle Society. 2022;7(4):2473011421S00922. doi:10.1177/2473011421S00922​

16. Clanton TO, Haytmanek CT, Williams BT, Civitarese DM, Turnbull TL, Massey MB, Wijdicks CA, LaPrade RF. A biomechanical comparison of an open repair and 3 minimally invasive percutaneous Achilles tendon repair techniques during a simulated, progressive rehabilitation protocol. American Journal of Sports Medicine. 2015;43(8):1957-1964. doi:10.1177/0363546515587082​

17. Melcher C, Renner C, Piepenbrink M, Fischer N, Büttner A, Wegener V, Birkenmaier C, Jansson V, Wegener B. Biomechanical comparisons of three minimally invasive Achilles tendon percutaneous repair suture techniques. Clin Biomech (Bristol, Avon). 2022;92:105578. doi:10.1016/j.clinbiomech.2022.105578

18. ​Traina F, Perna F, Ruffilli A, Mazzotti A, Meliconi R, Berti L, Faldini C. Surgical treatment of insertional Achilles tendinopathy: a systematic review. J Biol Regul Homeost Agents. 2016;30(4 Suppl 1):131-138.

19. Fradet J, Lopes R. Endoscopic Calcaneal Speedbridge technique: Decreased postoperative complication rate in insertional achilles tendinopathy. Orthopaedics & Traumatology: Surgery & Research. 2024;110(5):103916. doi:10.1016/j.otsr.2024.103916

20. ​She G, Teng Q, Li J, Zheng X, Chen L, Hou H. Comparing surgical and conservative treatment on Achilles tendon rupture: a comprehensive meta-analysis of RCTs. Front Surg. 2021;8:607743. doi:10.3389/fsurg.2021.607743.

21. Lipman JD, Smith E, Rispoli DM, Orzechowski J, Sweeney K, Ho B, Patel M, Wapner KL. Jigless knotless internal brace versus other minimal invasive Achilles tendon repair techniques in biomechanical testing simulating the progressive rehabilitation protocol. J Foot Ankle Surg. 2022;61(4):761-766. doi:10.1053/j.jfas.2022.01.009​

22. Nakajima K. Fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement for insertional Achilles tendinopathy: surgical techniques. Arthroscopy Techniques. 2023;12(6):e855-e860. doi:10.1016/j.eats.2023.02.018 ​

23. Lopes R, Padiolleau G, Fradet J, Vieira TD. Endoscopic Speedbridge procedure for the treatment for insertional achilles tendinopathy: The snake technique. Arthroscopy Techniques. 2021;10(9). doi:10.1016/j.eats.2021.05.014

24. Ikuta Y, Nakasa T, Kawabata S, Adachi N. Achilles Tendon Reconstruction Using a Hamstring Tendon Autograft for Chronic Rupture of the Achilles Tendon in Patients Over 70 Years of Age: A Retrospective Case Series. Cureus. 2023;15(8):e42788. Published 2023 Aug 1. doi:10.7759/cureus.42788

25. Beitzel K, Mazzocca AD, Obopilwe E, Boyle JW, McWilliam J, Rincon L, Dhar Y, Arciero RA, Amendola A. Biomechanical properties of double- and single-row suture anchor repair for surgical treatment of insertional Achilles tendinopathy. American Journal of Sports Medicine. 2013;41(7):1642-1648. doi:10.1177/0363546513487061.​

26. Sankova MV, Beeraka NM, Oganesyan MV, Rizaeva NA, Sankov AV, Shelestova OS, Bulygin KV, Vikram PRH, Barinov AN, Khalimova AK, Reddy YP, Basappa B, Nikolenko VN. Recent developments in Achilles tendon risk-analyzing rupture factors for enhanced injury prevention and clinical guidance: Current implications of regenerative medicine. Journal of Orthopaedic Translation. 2024;49:289-307. doi:10.1016/j.jot.2024.08.024.