Achilles Tendon Rupture Repair

Stanley C. Graves, MD

Jaycen C. Brown, MD

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Graves and Dr. Brown.

INTRODUCTION

Intrasubstance rupture of the Achilles tendon is commonly a sports-related injury of patients in their 40s or 50s. Patients commonly give this history: “I feel like someone shot me in the back of the leg.” A palpable gap is present in the substance of the Achilles tendon. There is often weakness in voluntary plantar flexion and increased passive ankle dorsiflexion in comparison with the opposite side. The classic examination is the Thompson test. With the patient kneeling on a chair or a stool, the examiner squeezes the calf. If the tendon is ruptured, the foot will not actively plantarflex. Diagnosis of acute rupture is generally straightforward. The American Academy of Orthopaedic Surgeons’ Clinical Practice Guidelines generally support surgical repair but advise caution in patients with diabetes, neuropathy, immunocompromised states, peripheral vascular disease, or local/systemic dermatologic disorders as well as in patients who are older than 65 years, use tobacco, have a sedentary lifestyle, or are obese.¹

Until recently, consensus in the United States favored acute surgical repair, with the thought that surgery provides greater strength with a decreased risk for rerupture.²^,³^,⁴ Surgery can be open, limited open, or percutaneous, with and without assistive devices.⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵ A recent controversial paper suggested comparable outcomes with a structured nonsurgical protocol.¹⁶ Augmentation with synthetic, biologic, or allogeneic material has been reported in both animal models and limited case series.¹⁷^,¹⁸^,¹⁹

This chapter will discuss the open technique used by the authors. This technique appears both safe and reliable for surgeons who only occasionally encounter such patients. When exposed, the ruptured ends are classically described as looking like the ends of a mop. The ends are frayed, and the tearing occurs diffusely throughout a significant length of the proximal and distal parts of the tendon. The surgeon should beware if the tear appears “clean” because this situation is likely representative of attempted healing in a previously injured tendon. This tissue should be excised to achieve a solid repair at an appropriate tendon length and tension.

PROCEDURE

Acute Achilles Tendon Rupture Repair

Surgical Technique

Patients have historically been positioned prone for ease of access. Alternatively, if the patient is not obese, and the ipsilateral leg will sufficiently externally rotate, a sandbag or “bump” can be placed under the contralateral hip to allow access for the posterior midline incision using figure-of-4 positioning. This avoids the risks associated with the prone position, which include the need for intubation, lung compression with ventilation-perfusion mismatches, and outflow obstruction of the lower extremity. Additionally, supine positioning does not increase the risk of infection, sural nerve injury, or rerupture.²⁰ A second benefit when the patient is positioned in this fashion is the ease of access to the flexor hallucis longus (FHL) tendon from the medial arch. After positioning is completed, access should be checked before making the incision.

An extensile form of incision should be considered to address wound breakdown or tendon rerupture, generally avoiding a curvilinear or transverse incision. A relatively midline incision allows distal extension if the FHL needs to be harvested to replace nonfunctional tendon or for augmentation of poor-quality tissue. A slight medialization of the skin incision also avoids the central watershed area described by Yepes et al and may help decrease the risk of surgical wound healing issues.²¹

The poor-quality, stringy tissue on both the proximal and distal aspects of the rupture should be débrided. The ankle can be plantarflexed to take tension off the repair. The surgeon should remember that most cadaver models of Achilles tendon repair are based on mechanical testing of tendons that have been surgically transected instead of violently ruptured.⁷^,¹⁰^,²² The method of repair is likely not as crucial as the method used in flexor tendon repair in the hand. A sound repair with a minimal amount of nonabsorbable suture material is probably best. I prefer the Krackow pattern, using a heavier suture material (No. 2 nonabsorbable suture) that will not easily tear out or fail
(Figure 1). The peritenon is generally shredded and will add little to the repair. After the repair is completed, the ankle should be gently dorsiflexed to 90° to determine the stability of the repair. This will allow confidence during the postoperative rehabilitation period. Augmentation with cultured fibroblast material, synthetic mesh, or allograft is rarely necessary in primary repair performed within a few weeks of injury. The use of drains to prevent postoperative hematoma is generally recommended but is optional. Skin closure should be meticulous, minimizing surgical trauma from retraction during the surgery or tissue forceps during the repair. The authors favor carefully placed sutures as opposed to skin clips.²³ The ankle should be immobilized in slight (5° to 10°) equinus to optimize blood flow to the posterior skin and avoid pinching of the skin around the posterior incision. The authors prefer a large bulky dressing underneath the splint (Figure 2).

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