Achilles Tendon Repair

Edited by Vinod K. Panchbhavi, MD

 

Indication

An Achilles tendon repair is often performed as treatment for a ruptured Achilles tendon.

Procedure

Open Achilles Tendon repair

An open Achilles tendon repair is performed through an approximately 3-inch incision running down the back of the ankle over the site of tendon rupture. Each of the ruptured tendon ends are sewn with suture, and the sutures from each end are tied to each other with the ankle pointing downwards so that the Achilles tendon is now under normal tension with the tendon ends touching each other. The wound is carefully closed and the ankle placed in a splint to protect both the wound and the repaired Achilles tendon as they begin to heal. (see Figure 1)

Mini-Open Incision

Minimally invasive approaches may also be used to repair the Achilles tendon and are often referred to as a “mini-open” technique (see Figure 2). In this procedure, a small incision measuring approximate half an inch is made over the Achilles rupture site. The Achilles tendon glides within a tendon sheath, and a special instrument is then used to pass sutures through the Achilles tendon and into this sheath using needles through the skin without making an actual incision running down the entire length of the repair, and the sutures are then pulled into the half-inch incision where they are tied. The “mini open” technique has the advantages of a smaller incision and a potentially lower rate of wound healing issues, but has the disadvantage of less visualization of the ruptured tendon and a potentially higher rate of associated nerve injury.

Figure 1: Open repair of Achilles tendon rupture

Figure 2: Mini-Open Incision Repair

Recovery

Typical Standard Recovery

Historically, after surgery patients would be placed in a cast with their toes pointing downwards for 6-8 weeks. More recently, studies have highlighted the importance of a functional rehabilitation protocol in which the ankle is briefly immobilized to let the wound heal, but, thereafter, gradually increasing activity is allowed. This often entails gently moving the ankle to cause just a little bit of motion and tension at the healing tear site so that the tendon heals more strongly and with a less disorganized scar, but not too much tension so that it stretches or even re-tears the repair. Weight-bearing is gradually allowed in a specialized boot with multiple wedges under the heel so that the toes continue to point downwards and the repair isn’t stretched. These wedges are gradually removed so that the ankle is brought upwards in a controlled fashion over the course of the initial weeks to months of recovery. Once out of the boot, progressive strengthening is allowed and a return to full sport participation generally takes 6-12 months.

Potential General Complications

• Asymmetric Gait (leading to pain elsewhere)
• Deep Vein Thrombosis (Blood Clot)
• Pulmonary Embolism (PE)
• Scar Irritation

Potential Specific Complications

• Wound healing: While wound healing issues are a concern anywhere on the foot and ankle, they are particularly concerning after an Achilles tendon repair because the tendon itself has relatively little soft-tissue coverage. Therefore, any type of wound healing problem can easily end up involving the tendon itself. For most patients, there is approximately a 2-5% chance of a wound-healing problem. Surgeons work hard to minimize these complications with careful soft tissue dissection and by trying to close the tendon sheath and skin separately to create a closure with multiple layers of protection, but the rate of wound complication can never be made 0%. Because of the increased risk among patients who smoke or who have poorly controlled diabetes, many surgeons will opt to treat Achilles ruptures in such patients without surgeries.
• Infection: A deep infection following an Achilles tendon repair can be a devastating problem. Often, an infection will occur if there is an associated wound healing problem that allows bacteria from the outside world to reach the actual Achilles tendon. Treatment may require not only antibiotics, but potentially the removal of all suture materials and, in some instances, removal of the tendon itself. One may even need the participation of a plastic surgeon to get the skin to heal.
• Re-rupture of the Achilles tendon: The Achilles tendon can re-rupture after a repair. With surgery, re-rupture rates range from 2-5%. These tendon re-ruptures can occur at any time in the recovery process, but commonly occur 6-18 months (or longer) after the original surgery. Historically the rate of Achilles re-rupture was higher if one chose to treat the Achilles rupture without surgery (7-12%). Functional rehabilitation programs have lowered the re-rupture rate in this latter group, though research studies vary in whether they find that the re-rupture rate is exactly the same with or without surgery in the setting of a functional rehabilitation protocol.

 

Previously edited by  Vinod K. Panchbhavi, MD

Edited July 10, 2019

mf/ 10.22.18