Abstract
Achilles tendon ruptures are common injuries among active individuals and are typically managed with primary end–to–end repair. However, postoperative infection remains a significant complication that may compromise tendon healing and functional outcomes. This case report presents a 29–year–old male who sustained an acute Achilles tendon rupture and subsequently developed wound necrosis and infection following primary repair. After undergoing multiple surgical debridements and achieving eradication of infection, definitive reconstruction was performed using a modified external Bunnell suture technique with nonabsorbable monofilament suture. Soft tissue coverage was achieved using a keystone perforator flap and a bipedicled flap. At 12–month follow–up, the patient demonstrated full strength, preserved range of motion, a normal gait, and no recurrence of infection. This case highlights the importance of staged management, minimizing foreign material in infected surgical fields, and utilizing reliable soft tissue reconstruction techniques to achieve successful outcomes in complex Achilles tendon revision surgery.
Introduction
Achilles tendon rupture is a relatively uncommon injury, with an estimated incidence of approximately 18 per 100,000 individuals. , Complications following surgical repair are well documented, with major complications occurring in approximately 10% of patients. , The most common complications include wound healing complications (7–13%), deep infection (2–4%), rerupture, and sural nerve injury. Identified risk factors associated with increased complication rates include diabetes mellitus, obesity, tobacco use, corticosteroid exposure, and collagen tissue disorders. ,
Revision surgery or management of infected Achilles tendon repairs can be particularly challenging. The tendon may become nonviable, friable, and associated with a segmental defect requiring reconstruction. , Additionally, compromise of the surrounding soft tissue envelope may necessitate flap coverage or other soft tissue reconstruction techniques. Even after successful tendon repair, retained suture material may serve as a nidus for persistent infection.
We present a case and surgical technique describing the management of an infected open Achilles tendon repair requiring serial debridements, tendon reconstruction, and soft tissue coverage. The Achilles tendon was reconstructed using a modified external Bunnell suture technique with a nonabsorbable monofilament suture designed to minimize the risk of infection associated with retained buried suture material.
Surgical technique
The patient received a popliteal nerve block in the preoperative holding area and was brought to the operating room. Following induction of general endotracheal anesthesia, the patient was placed in the prone position, and the left lower extremity was prepped and draped in the usual sterile fashion. The open wound and Achilles tendon were sharply debrided to healthy, bleeding tissue. Following debridement and copious gravity irrigation, the extremity was re–prepped and re–draped, and the surgical team changed gloves. Post–debridement tissue cultures were obtained.
Case report
A 29–year–old male with no significant medical history sustained an acute left Achilles tendon rupture while playing basketball. The patient reported feeling a “pop” in his ankle while jumping for a layup, followed by immediate pain and inability to plantarflex the ankle. He was evaluated in the emergency department and placed in a splint.
The patient was an active individual who desired return to sports. His history was notable for smoking one pack of cigarettes daily and a self–reported history of “wound healing issues” without documented etiology. Given this concern, a metabolic and immunologic workup was performed, including complete blood count, comprehensive metabolic panel, inflammatory markers, and hemoglobin A1c. Results were unremarkable, with no evidence of diabetes, peripheral vascular disease, autoimmune disease, or other systemic conditions affecting wound healing. Tobacco use was his only identifiable risk factor.
Physical examination demonstrated a positive Thompson test and a palpable defect within the midsubstance of the Achilles tendon. Magnetic resonance imaging confirmed a complete Achilles tendon rupture ( Fig. 1 A,B). After discussion of treatment options and increased wound complication risk associated with smoking, the patient elected operative repair.
A,B Sagittal and Axial views ankle MRI demonstrates partial tear of the distal Achilles tendon with minimal residual fibers intact extending from its insertion approximately 6 cm proximal to its attachment more prominently along the medial aspect of the Achilles tendon.
Primary Achilles tendon repair was performed using a Krackow stitch technique with No 2 braided ultra–high–molecular–weight polyethylene suture (FiberWire). Early postoperative healing was appropriate; however, subsequent follow–up demonstrated progressive wound edge necrosis and dehiscence despite local wound care and activity restriction.
Due to concern for deep infection, exposed tendon, and retained suture material, the patient underwent admission for serial irrigation and debridement. During the initial debridement, the FiberWire repair construct and all nonviable tendon tissue were removed. Intraoperative cultures grew Staphylococcus aureus , and intravenous cefazolin was initiated. A repeat debridement with negative pressure wound therapy was performed three days later. Following negative repeat cultures, the patient completed a two–week course of oral trimethoprim–sulfamethoxazole and was discharged with negative pressure wound therapy. After resolution of infection, definitive Achilles tendon reconstruction was performed.
Surgical technique
The patient received a popliteal nerve block and underwent general anesthesia in the prone position. The left lower extremity was prepared and draped in standard sterile fashion. The wound and Achilles tendon were sharply debrided to healthy bleeding tissue, followed by copious irrigation, repeat preparation and draping, glove exchange, and collection of tissue cultures.
A 4–cm defect was identified between the viable proximal and distal Achilles tendon ends. The remaining tendon was significantly attenuated, measuring approximately one–third of its original thickness.
With the ankle held in maximal plantarflexion, a No 0 Prolene monofilament suture was passed percutaneously approximately 2 cm proximal to the tendon stump and advanced through the Achilles tendon substance. The suture was sequentially passed through the proximal and distal tendon ends in a modified external Bunnell configuration using alternating longitudinal and transverse passes while avoiding violation of the peritenon and skin. The technique was repeated from the contralateral side to create a symmetric repair construct.
The sutures were tied externally with the ankle maintained in maximal plantarflexion, restoring tendon continuity ( Fig. 2 ). Approximately 5 mm of residual tendon gapping remained following maximal approximation. A meshed Integra bilayer matrix was placed within the residual defect as a biologic scaffold to occupy dead space and support tissue incorporation. The matrix was not intended as a structural tendon augmentation, with tensile strength provided solely by the modified external Bunnell repair.
modified external Bunnell suture repair step by step schematic.
The wound was closed with interrupted vertical mattress sutures using 2–0 Prolene ( Fig. 3 A,B).
A,B Intraoperative clinical images of revision Achilles repair with external modified Bunnell technique.
Postoperative course
The patient developed postoperative skin edge necrosis requiring soft tissue reconstruction three weeks later with a medial ankle keystone perforator flap and lateral bipedicled flap ( Fig. 4 A,B). The Achilles reconstruction remained intact throughout the procedure.
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