32 Open Achilles Rupture Repair Abstract The overall incidence of acute Achilles tendon rupture has been steadily rising with the Achilles being the third most commonly injured tendon in the body. These occur most commonly in male recreational “weekend warrior” athletes in their fourth decade, with injury occurring during sports participation. The Achilles tendon experiences the highest tensile loads of any tendon in the body, often up to 10 times the body weight during athletic activity. Rupture can lead to significant functional morbidity if not adequately treated. Optimal treatment of acute Achilles tendon ruptures remains controversial between formal open repair, limited more percutaneous surgical repair, and nonoperative treatment. While the details of this debate are beyond the realms of this chapter, the major concern with open repair remains the risk of wound healing complications, which range from 3% for deep infections to more than 10% for overall complications. This chapter aims to present surgical tips and pearls to limit the risk of wound complications while optimizing strength of the tendon repair and allowing for an early and aggressive rehabilitation process. Keywords: Achilles tendon, Achilles rupture, open Achilles repair, Achilles rupture rehabilitation • Acute rupture of the Achilles tendon: • Patients may have symptoms of Achilles tendonitis prior to the acute rupture, with degenerative changes see in micro-pathological evaluation of the ruptured tendon ends in the majority of cases.1 • Sports participation is involved in about 70% of injuries: • Injury most commonly occurs in the watershed hypovascular zone of the tendon, approximately 5 to 7 cm from the calcaneal insertion. • Ruptures usually occur during eccentric contracture of the tendon during forceful ankle dorsiflexion. • Patients often give a history of hearing a pop at the time of the injury. • The feeling is described as being kicked, hit with a bat, or being shot in the back of the ankle. • A high degree of suspicion is required so as not to miss an Achilles tendon rupture, which is reported to occur in 10 to 20% of times in the emergency room, particularly in older patients (> 55 years old), obese and diabetics patients, and those not participating is sports at the time of the rupture. • Patient should be evaluated prone with both legs exposed, and with their knees bent at 90 degrees and both limbs examined. • There are three cardinal findings of an acute Achilles tendon rupture. When all three are present, the diagnosis is present in 100% of cases.2 These are as follows: • In most cases, no radiographic studies are required. • Plane radiographs are only indicated if an insertional rupture (evaluate for a Haglund process and insertional spurs), or calcaneal avulsion fracture is suspected. • Tertiary studies such as MRI or ultrasound are usually unnecessary when the clinical evaluation is consistent with an acute rupture. • Many different nonoperative treatments have been described. These include the following: • Nonoperative treatment has been shown to have a significantly higher rerupture rate.3,4 • Medical comorbidities (high anesthesia risk). • Infection at/near surgical site. • High risk of incision-related complications: • Inability to comply with postoperative instructions. • Low functional demand. • To provide a contiguous Achilles tendon with adequately strong repair to allow rapid rehabilitation and long-term return to prerupture functional levels of activity. • Ability to debride tendinotic edges of rupture. • End-to-end anastomosis of Achilles tendon. • Allows multiple locking suture loops at each end of the ruptured tendon. • Full visualization of tendon. • Allows early weight-bearing and rehabilitation. • Lower rerupture rates than nonoperative treatment. • Stronger muscle function. • Low incidence of sural nerve injury. • Limit wound complications by performing full-thickness incision, deep compartment fasciotomy, limited retraction, and adequate wound closure. • Stable fixation with locking Krackow’s stitches on each end of tendon. • Rigid repair at the rupture site with multiple knot repair. • Ensuring strong enough repair to allow early rehabilitation. • Supine with a large hip bump under the contralateral hip (Author’s preference; Fig. 32.1). • Can be positioned prone on chest rolls: Fig. 32.1 Supine positioning with hip bump under contralateral hip and surgical leg internally rotated. • Thigh tourniquet (calf tourniquet will squeeze the gastrocnemius-soleus calf muscle making assessment of Achilles length at repair difficult). • Leg should be elevated for exsanguination: • Full thickness 6to 8-cm longitude incision over the medial border of the Achilles tendon (Fig. 32.2): • Incision centered over the region of the Achilles tendon rupture. • Digitally mobilize both ends of the tendon (especially proximally) to free any adhesions or contractures that may have occurred since the rupture (Fig. 32.3). • Tendon ends are then debrided by sharp dissection resecting nonviable and tendinotic tissue usually found at the rupture ends (Fig. 32.4). Minimize the amount of tendon being resected.
32.1 Indications
Less than 4 weeks from the injury.
Less than 3-cm retraction gap.
32.1.1 Pathology
Basketball is the most commonly causative sport in the United States.
Soccer is the most common causative sport in Europe.
32.1.2 Clinical Evaluation
Diminished resting tension of the ankle compared to the unaffected side (which usually rests at 20 degrees of equinus with the knee flexed).
Gentle palpation along the tendon will usually detect a defect within the tendon—most commonly 5 to 7 cm from the calcaneal insertion.
Thompson’s test (gentle squeezing of the gastrocnemius-soleus calf muscle) will result in plantar flexion of the ankle with an intact tendon. In a case where the tendon is ruptured, a small “flicker” of plantar flexion motion may occur due to intact deep compartment flexors, but will be less than/asymmetric to the uninvolved normal limb.
The ability of the patient to actively plantarflex the ankle does not exclude an acute Achilles rupture.
32.1.3 Radiographic Evaluation
Subtle signs on plane radiographs include the following:
Loss of sharp contour of Kager’s fat pad.
Anterior translation of the Achilles tendon shadow (no longer parallel to the skin): Arner’s sign.
These studies are costly and may delay time to treatment.
Indications for magnetic resonance imaging (MRI)/ultrasound:
Inconsistent clinical examination.
Prior rupture or Achilles surgery.
Chronic rupture more than 4 weeks old or to quantify suspected gap greater than 3 cm.
Known chronic Achilles tendinosis.
32.1.4 Nonoperative Options
Cast treatment with the ankle in plantar flexion.
Boot immobilization.
Functional bracing with early weight-bearing:
This has been shown to have the best outcomes of nonoperative treatment.
Requires close vigilance and monitoring.
32.1.5 Contraindications
Uncontrolled diabetes.
Steroid use.
Poor circulation.
32.2 Goals of Surgical Procedure
32.3 Advantages of Surgical Procedure
32.4 Key Principles
32.5 Preoperative Preparation and Patient Positioning
This requires patient to be intubated, and has a longer setup time.
Preferable not to use Esmarch, which may lead to DVT (deep vein thrombosis)/PE (pulmonary embolism).
32.6 Operative Technique
32.6.1 Surgical Approach
Through skin subcutaneous tissue down to and through the paratenon.
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