Endoscopic-assisted Achilles tendon repair with plantaris tendon augmentation

Six portals are made at the sides of the Achilles tendon. The plantaris tendon is harvested and retrieved to the distal-medial portal. The investing fascia of the Achilles tendon is released at the medial border of the tendon. The suture is passed through the tendon end through the medial portal and exits at the tendon surface and then the fascia and skin. The suture is retrieved at the tendon surface through the medial portal. The loops of the suture are retrieved through the proximal-medial, proximal-lateral, and lateral portals, and a loop of suture is then formed at the surface of the tendon and beyond the boundary of the tendon. The suture is passed through the tendon again in a deep-to-superficial direction within the loop and is retrieved through the proximal-medial portal. The suture is tensioned, and a locking stitch is formed. The loops of the suture are retrieved through the medial, lateral, and proximal-lateral portals. The suture is then passed through the tendon in a deep-to-superficial direction and is retrieved again through the proximal-medial portal, and the second locking stitch is formed. This is repeated 3 to 4 times over the medial side of the proximal tendon through the proximal-medial portal, and the suture is then passed to the proximal-lateral portal at the surface of the tendon. Locking stitches are then applied to the lateral side of the tendon. The same procedure is then repeated over the distal tendon with another suture. The tendon ends are approximated with the pair of sutures tied through the medial and lateral portals. The plantaris tendon is passed through the Achilles tendon with a pointed tendon passer through the proximal and distal portals. The plantaris tendon is then looped around the Achilles tendon and sutured to it.