Steven Kodros

1. Acute rupture of the Achilles tendon in a competitive or high-level athlete

2. Acute ruptures of the Achilles tendon in which treatment has been delayed: the exact length of delay that “requires” operative intervention is debatable, but treatment delays beyond approximately 2 weeks generally increase the benefits of surgery. In the event that treatment has been extensively delayed (e.g., greater than 6 to 8 weeks), surgical repair of the ruptured Achilles tendon may require additional augmentation with fascial turndown flaps or flexor hallucis longus tendon transfer.

1. Poor skin or soft tissue condition in the area of desired surgical repair

2. Patients with conditions that may increase the risk of wound-healing problems (e.g., peripheral vascular disease, diabetes mellitus, heavy tobacco use) (relative)

1. Evaluate the patient to assess the benefits of surgical versus nonoperative treatment.

2. Discuss both surgical and nonsurgical treatment (and their respective pros and cons) options with the patient.

3. If a calcaneal avulsion fracture is suspected, radiographs of the ankle and foot may be beneficial.

4. While an appropriate history and physical examination can reliably identify most Achilles tendon ruptures, consider obtaining a MRI if diagnosis is in doubt.

1. If augmentation with the plantaris tendon or other additional procedures is being considered, tendon strippers and weavers may be beneficial.

2. The procedure is usually done with the patient in the prone position. However, if desired, the procedure can be done with the patient supine by placing a rolled blanket beneath the contralateral buttock to externally rotate the affected limb.

3. A thigh tourniquet is utilized.

4. The procedure is done with either general or spinal anesthesia.

1. Preoperatively, pay close attention to the normal plantarflexion resting position and tone of the contralateral foot and ankle in order to reproduce this as best as possible when repairing the ruptured side. If necessary, both lower extremities can be prepped and draped to allow this comparison intraoperatively.

3. Use a medial incision. This avoids the sural nerve laterally and allows better access to the plantaris, flexor hallucis longus, and flexor digitorum longus tendons that are occasionally required for augmentation of the repair.

4. Make sure all suture knots in the repair are deeply buried and do not lie superficial under the wound closure.

5. Carefully close the paratenon in order to relieve tension on the skin closure and minimize wound complications. If this closure is tight or difficult to perform, consider making a longitudinal relaxing incision in fascia of the deep posterior compartment immediately anterior to the Achilles tendon.

1. Avoid excessive undermining or subcutaneous tissue dissection superficial to the paratenon layer.

2. Attempt to avoid making the reconstructed tendon either too long or too short. The goal is to repair the tendon so it returns as close to its normal length as possible.