Acute Achilles Rupture

Sydney C. Karnovsky

Mark C. Drakos

Positioning

Place the patient in a prone position.
Place a nonsterile tourniquet on the operative thigh. Prep and drape the lower extremity in a sterile manner.
Exsanguinate the lower extremity and inflate the tourniquet 250 mm Hg.

Surgical Approach

Identify the Achilles, and make an incision over the tendon (Figure 13-1).
- Cheat medial to midline because of improved vascular supply.
  
  Figure 13-1. The incision over the Achilles tendon has been made, exposing the paratenon.
Base the size and location of the incision on the location of the rupture.
- Try to keep incision 2.5 to 3.5 cm or less. Cheat on the higher side of the tear. The inferior Achilles can be delivered into the wound with ankle plantar flexion. If you have a magnetic resonance imaging report to establish the distance of the tear from the Achilles insertion in the calcaneus, this can be helpful for planning. Otherwise, feel for the palpable defect.
Incise the paratenon sharply in line with its fibers. Evacuate hematoma.
Dissect the incised area to the level of the Achilles tendon.
Identify the area of rupture. Identify whether there is associated tendinopathy—look for small tears, tissue integrity, and tissue quality (Figure 13-2).

Figure 13-2. The ruptured tendon is identified.
If there is no degeneration and only an acute rupture, repair the tendon without the use of an additional tendon graft.
- Mobilize the ends of the tendon using a periosteal elevator to release any adhesions (Figure 13-3).
  
  Figure 13-3. The ends of the tendon are mobilized.
- Use a #2 orthocord in a modified Krackow manner to create medial and lateral limbs in the proximal and distal aspect of the tear (Figure 13-4).
  - You can use a PARS device (Arthrex). Using it proximally is not recommended because of the proximity of the sural nerve. However, distally there is usually enough distance between the Achilles and sural nerves, where iatrogenic injury to the nerve is usually less likely. However, if you can mobilize the distal Achilles and get adequate bites of tissue with a Krakow suture, you can eliminate this step (Figure 13-5).
    
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