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Achilles tendon rupture- Open repair technique

    Overview

    Learn the Achilles tendon rupture: Open repair technique surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Achilles tendon rupture: Open repair technique surgical procedure.
    A surgical repair of the Achilles tendon is required in the active patient in whom the tendon ends are demonstrated not to be in adequate apposition(under ultrasound imaging) when the ankle is placed into full equinus.
    Another indication for surgical repair of the ruptured Achilles tendon is a delayed presenting Achilles rupture, irrespective of how well tendon ends appose. The definition of delayed here is open to interpretation though numbers in weeks. In this scenario the repair may need to by augmented by some form of tendon transfer. One example if the Flexor Hallucis tendon transfer which can be read on Achilles Reconstruction :Flexor Hallucis Longus tendon transfer using Arthrex Biotenodesis screw . Apart from these situations most cases are open to debate.
    Recognition has increased over recent years that these injuries are associated with an increased risk of DVT, so appropriate prophylaxis should be used and calf symptoms investigated aggressively.
    Operative alternatives to the open technique are percutaneous repairs using purpose designed jigs such as the Integra Achillon which is detailed at Integra Achillon to repair Achilles rupture



    Indications

    INDICATIONS:
    -Acute complete rupture of Achilles tendon: A surgical repair of the Achilles tendon is required in the active patient in whom the tendon ends are demonstrated not to be in adequate apposition(under ultrasound imaging) when the ankle is placed into full equinus.
    –Sub-acute presentation of Achilles rupture: There is evidence that a direct repair may be effective a number of weeks post-injury but equally there should be a low threshold in these cases to augment with a tendon transfer such as the Flexor Hallucis Longus.
    SYMPTOMS & EXAMINATION
    The classical presentation occurs in most patients with the sensation of being kicked in the Achilles and on occasion this includes an audible “crack”. Patients are almost always unable to continue any meaningful weight-bearing on the effected leg and a fair degree of swelling and bruising ensues rapidly. The latter in my experience is not an invariable feature. If the Achilles tendon sheath does not rupture(which is an occasional finding at surgery) then any haematoma remains contained, which explains why some cases do not bruise.
    The patient will not be able to perform a single heel rise, but a double heel rise (with weight bearing upon the uninjured side) will be possible and is therefore a useless test to perform. It may be possible to palpate a defect in the tendon but swelling may preclude this. With the patient relaxed and supine gentle dorsi-flexion on the injured side should produce a significant increase in the detectable movement given the Achilles is the major posterior restraint to ankle dorsi-flexion.
    With the patient prone a calf squeeze will not produce ankle plantar-flexion if the Achilles tendon is ruptured. The amount of movement resulting even when the tendon is intact can be subtle and so the un-injured side should be examined first.
    The risk for clinicians (and patients) comes with those who present late. By 2 weeks there is little residual local Achilles pain and the injury may be described to the clinician as an “ankle sprain”. A low index of suspicion should be had for all ankle injuries presenting late and Achilles rupture looked for in all.
    The Flexor Hallucis Longus transfer however is an excellent salvage operation for a delayed presenting case that is not suitable for direct tendon repair.
    Direct repair may also be appropriate & possible for a delayed presenting rupture a number of weeks after the event. There needs to be significant “freshening” of the tendon ends to encourage new bleeding and healing at the repair site as this stage at the time of operation. In the situation of delayed presentation even if the tendon ends sit well together they are not likely to adhere to each other having been separated for a number of weeks (See paper by Carden et al in results section).
    It is worth emphasising that there is an increased incidence of DVT recognised as complicating this injury. The warning sign is usually a change in the status quo. Most patients will suffer venous congestion once the limb is in cast (swelling and colour changes , accentuated when the limb is dependent). An increase in these symptoms or the onset of calf pain (which is not usual after the initial early acute pain of Achilles rupture) should mandate immediate exclusion of DVT.
    One similar , but rarer diagnosis, compared to the Achilles rupture which presents very similarly is an avulsion of the Achilles insertion. Bruising tends to be just located very distally and this variant usually requires operative reattachment.
    INVESTIGATION:
    It is possible to diagnose an Achilles rupture clinically in most cases for a clinician with experience(or at least to have a very high index of suspicion). Imaging is of use when the diagnosis is equivocal or if conservative treatment is being contemplated to detect how well the tendon ends oppose, or if the deep veins require imaging.
    Ultrasound:An ultrasound scan is the investigation of choice. In skilled hands this will allow not only confirmation of diagnosis but also whether the tendon ends sit it good apposition. A dynamic assessment can also be made by placing the foot into full equinus to see if this improves tendon end contact. There is no defined amount of tendon lengthening (if the ends do not oppose) that is established as being “acceptable” in an active and fit patient. Age, function, co-morbidities and whether the tendon ends come completely together on ultrasound assessment should be considered in conjunction if contemplating operative repair.
    A further benefit of ultrasound is the fact that the deep calf veins can be imaged for DVT at the same sitting. There is a recognised increased incidence of DVT associated with Achilles rupture (as well as cast immobilisation).
    There is legitimately considerable debate about the optimal treatment of these injuries. As long as the tendon is encouraged to heal at its previous length (which is now more definable than previously due to widespread MSK Ultrasound services) then it is difficult to understand why logically the outcome should be better if operatively repaired.
    If however a quality Ultrasound service is not available a low threshold for repair is sensible.
    MRI:In my experience this is more often equivocal in terms of whether a complete rupture is present and is less able to determine how well tendons ends are opposed. On this point it is a static examination and it is not possible to dynamically assess whether tendon ends oppose differently/better in changing the foot position.
    OPERATIVE ALTERNATIVES.
    Percutaneous repair of the Achilles: Lower incidence of soft tissue complications but a more technically exacting technique.
    V to Y plasty of the proximal tendon /muscle junction: This provides adequate mobilisation if the proximal tendon very retracted.
    Achilles turn-down flap: For tendon defects again if the ends do not oppose adequately
    Repair using allograft tissue: To reinforce tendon defects. Attention must be paid to ensuring appropriate of the Achilles
    CONTRAINDICATIONS.
    Caution needs to be exercised in patients with poor vascularity , poor skin quality , diabetes and immuno-suppresive medications or steroids. The operation is not contra-indicated but the chance of wound infection or break down higher and patients should be consented appropriately. Protracted wound healing and the requirement for secondary reconstructive plastic surgery are rare eventualities that patients need to be aware of and Surgeons need to be realistic about.
    In patients with previous Achilles surgery the old scars should generally be re-used to avoid the risk of producing a narrow skin bridge between two scars which may result in skin necrosis.
    In low demand and elderly patients a chronically deficient Achilles may be best managed with an AFO type splint and appropriate rocker soled footwear. Age by itself is not a contraindication to surgery.
    Patients must be willing to adhere to the post-operative protocol.

    Rupture of the Calcaneal tendon: Early and late management. Carden et al
    J Bone Joint Surg 1987 69-B) (3):417-20

    Setup

    Almost all Achilles repairs can be carried out with the patient supine
    The incision used most sensibly is not a direct posterior one onto the tendon but postero-medial & just anterior to the tendon
    One or two side supports should be placed on the operated side at thigh and trunk level whilst several sandbags are placed under the opposite buttock , thus turning the operated leg into 90 degrees of external rotation
    The further addition of rolled up sterile towels allow an extra element of helpful rotation and access to the back and lateral aspects of the tendon
    Thigh tourniquet to be used
    Prophylactic antibiotics and LMWHeparin peri-operatively & post-operatively
    Bipolar diathermy

    Operation – 1

    The leg is positioned in 90 degrees of external rotation and on sterile, rolled up drapes. This is done with the patient in the supine position rather than prone position.

    This does require significant bolsters to be placed under the contra-lateral hip and for the patient to be very securely held on the table with well padded side supports. It is still easier than having to turn the patient prone, as is more traditional.
    One can see a subtle concavity in the line of the tendon where the rupture is.

    The rupture is next palpated and its location identified when possible, which is not always the case if significant bruising and swelling are present.
    The skin incision is then centred on the area of rupture.

    The skin incision is made postero-medial and just skirting the anterior border of the Achilles tendon in the zone of injury. The incision is placed away from the direct posterior aspect of the tendon. This makes the scar less likely to both rub on shoe-wear and also adhere to the tendon (as the fat layer is better postero-medially).
    Should later surgery be required ( or primary direct repair prove not possible ) then the Flexor Hallucis Longus can easily be accessed via this approach.

    A direct scissors dissection is used down onto the deep fascia through the fat layer.
    Self retainers should be used as briefly as possible during each stage with care taken to place them well beneath the skin edges. Wound healing is an issue in this area and the skin perfusion may already have been impacted by the swelling and bruising that accompanies the injury.

    Further development of the deeper aspect allows clarification that in this case the tendon sheath is intact.
    Contained haematoma is clearly seen. The sheath should be preserved as a discreet layer as far as is possible.
    The sheath remaining intact is probably why some cases have little bruising evident post injury. It is also probably the reason that some late presenting complete ruptures present with a tendon which is very clearly in-continuity, having been able to heal in an elongated fashion (splinted by the sheath and with the haematoma contained and bridging the rupture).

    The sheath is opened longitudinally and preserved as a discreet layer for later closure where possible. It is often ruptured but some attempt to define it as a discreet layer for later closure over the tendon should be made.Once the sheath is opened it is obvious that the nature of the injury is a complete rupture of the Achilles tendon.
    The tendon ends are next mobilised within the sheath , care being taken to preserve the sheath and haematoma removed. The sheath can be a useful additional layer to close over the tendon (or incorporate into the repair if required) if it remains intact as in this case.
    If a plantaris tendon is present (which is the case in approximately 20% of the population) it is mobilised at this stage. That means one end is left attached and the other sectioned to give as long a length of tendon as possible that can be used to route across the rupture and double back on itself.

    Haematoma is removed and any adhesions that have formed between the tendon ends and covering sheath should be broken down(easiest often with finger tips) to allow the tendon ends to be mobile.The proximal extent of the wound has been advanced to allow better definition, and capture, of the Achilles.

    The deep fascia(1) overlying the FHL muscle & tendon sits anterior to the Achilles.
    Also deep to this fascia & located approximately in the area marked 2 is the neuro-vascular bundle.
    The neurovascular bundle is beneath the deep fascia and as long as this is not opened will be out of the operative field. If a careful dissection is made then it is easy to see, or palpate, beneath the fascia.
    For a straightforward Achilles repair you won’t need to be in this area.
    See Flexor Hallucis Longus transfer operation for a full dissection of this area.

    The now mobile tendon ends are sharp dissected back to good, repairable tissue.How much to resect is a matter of judgement but generally just enough.
    For the first few days after a rupture most of this tendon tissue remains of good quality but as days tick by it tends to deteriorate and hold suture material less well.

    The proximal end of the tendon is mobilised more formally following debridement by blunt and finger dissection around it within the sheath. This is an important step as its the proximal end that will have retracted (though it doesn’t always).Free up the proximal tendon fully with a combination of blunt finger dissection up into the proximal sheath as well as using long scissors. Not only should the proximal tendon be fully mobile but it should be possible to get/see above the injured zone of the tendon for suture placement if required.
    If at this stage the tendon does not easily pull down to meet its distal end the ankle can be placed into a degree of equinus which should enable the repair to start with a “core” suture. The aim should be for the repaired tendon to be as close to neutral plantar-flexion as possible.
    Slight equinus is permissible as this can be brought fully to neutral usually by the end of operation and if not by the 2 week cast change. Once a number of sutures have been placed it should be possible to put some slight tension on the repair and bring the ankle closer to neutral if its tight at this stage.

    The defect is measured (for interest only) to 3.5 cm . In cases of delayed presentation it can be up to 10cm. In this delayed situation with a large gap present additional measures may be required. These include a turn-down type flap from the central Achilles itself to bridge the gap, a V to Y lengthening of the proximal tendon /musculotendinous junction to allow easier mobilisation of the proximal end of the rupture or a tendon transfer to bridge the gap such as Flexor Hallucis Longus.
    As important as providing tissue to reconstruct the Achilles so that it is in continuity is that the repair is tensioned appropriately (commensurate with the uninjured side).

    An absorbable 1 Vicryl suture is used to take the first bite of the tendon, entering the ruptured surface from distal (1) and exiting proximally through sound tendon tissue (2).A good bite is required. This deeply place stitch is known as the core suture. More commonly non-absorbable braided sutures are used (such as Ethibond or Fibrewire).
    In making ones decision it is worth recalling that a complete tendon rupture heals rapidly even when treated conservatively so my practice has moved away entirely fro non-absorbable sutures here.

    The needle is fully exited proximally (1) and then sewn transversely across the width of the tendon to its other side (2), again taking a good bite of the tendon. The needle is fully exited proximally (1) and then sewn transversely across the width of the tendon to its other side (2), again taking a good bite of the tendon.

    The suture is then sewn back out of the ruptured end of the tendon, leaving two free tendon ends at the site of rupture.

    The pull out strength of the suture in the tendon is tested.
    If its starting to pull through then repeat the same suture pattern again, at a slightly different level of the tendon.

    The pull out strength of the suture in the tendon is tested and its ability to deliver the proximal tendon for repair checked by applying traction to the proximally placed stitch.
    This type of design is one half of a” Kessler “stitch. The same design will be repeated on the other side of the rupture.
    Other designs for the core stitch exist such as Bunnel and Krakow stitches.

    The same suture is continued into the distal tendon and a one cm bite or so taken( enough to ensure sound tissue is being repaired), from the central portion of the tendon, then exiting from the outer surface. This suture is the passed back into the tendon & across the width of the Achilles, to exit the opposite side of the tendon, as was done proximally.

    This suture is again passed back into the central portion of the tendon and exited proximally through the rupture site.The first Core suture is now placed.

    The adequacy of the hold in the Achilles tendon is tested by opposing the tendon ends under tension using the suture, but at this stage the suture is not tied.

    A second core suture is placed, using exactly the same technique, but aiming for a slightly different level of tendon to avoid snagging the new stitch in the existing suture material.

    One both core sutures have been placed they are both tied under appropriate tension.A useful instrument to assist in this is the knot holding forceps seen here. These have smooth jaws and do not risk abrading and rupturing the suture as it is tied under tension.

    A sound initial repair after core suture has been tied.

    Further & significant strength is given to the repair by adding a running suture all the way around the site of the rupture.
    The first bite of the circumferential suture using 1 Vicryl.
    Again sound and large bites of tissue should be aimed for.

    The suture is run from the anterior aspect of the tendon all the way round its circumference as a continuous stitch, until arriving back at the initial locked suture, which it is sewn onto.Again the robustness of the repair once complete is tested by plantar / dorsiflexion of the ankle.
    A further running circumferential suture could be used if the tissue is very poor or an additional initial Kessler type suture added.
    The tendon sheath that was carefully preserved should be closed around the tendon with a 2.0 Vicryl suture, following which further sutures are placed to close the fat layer, into which a drain is placed.

    Closure is with subcuticular Vicryl. Care should be taken to get a “water-tight “ skin closure with minimal/no edge overlap , to avoid producing an exudative wound from the skin edges.Exudate tends to irritate the skin edges, lead to maceration and contribute to wound break-down.

    Operation – 2

    A T2 weighted saggital MRI showing clearly high signal and loss of tendon at the junction of middle and lower thirds of the tendon.

    A T1 weighted saggital MRI showing clearly high signal and loss of tendon at the junction of middle and lower thirds of the tendon.

    Post Operative

    5-6 weeks in below knee cast post-operatively non-weight-bearing.
    Dressing changes at 1 & 2 weeks.
    Long Air-cast boot to follow after 5-6 weeks.
    Of highest importance through-out the post-operative period is that the wound is looked after.
    Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoe-wear especially after a patient is out of cast.
    Any exudate from the wound which is allowed prolonged contact with the wound will further exacerbate any skin breakdown.
    Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I routinely advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed.
    Showering & bathing is allowed from when out of cast.
    Commence range of motion exercises and non-weight bear strengthening regime from when out of cast.
    Avoid pushing Ankle dorsiflexion range early as this risks over-lengthening/stretching the newly repaired tendon
    Increase weight bearing as comfortable in boot , likely able to come off crutches by 8-9 weeks post op.
    Commence a weight-bearing rehabilitation routine (focusing on strength & balance protocols) from when the patient is able to full weight bear.
    A static bike can be used from 8 weeks and Cross-training from 10 weeks is achievable.
    Light jogging on treadmill from 11-12 weeks at soonest ( or sooner on an Alter-G treadmill or in a pool).

    Recommended Reading

    Operative versus non-operative treatment of acute Achilles tendon ruptures. A multicentre RCT.
    J Bone Joint Surg.2010. 92-A.2767-2775.
    K.Willits , A.Amendola et al.
    An RCT in which 72 patients treated with operative repair & 72 with accelerated rehabilitation program. Diagnosis on clinical grounds only and only included if within 14 days of injury. Assessed at 1 year & 2 years.
    No difference in functional results though higher soft tissue complication rate in operative group. Similar re-ruptures (2 in operative and 3 in non-operative).
    Combined conservative and orthotic management of acute ruptures of the Achilles tendon.
    J Bone Joint Surg.2004.86-A;1198-1202
    R.G.H.Wallace , I.E.R.Traynor ,W.G.Kernohan , M.H.A.Eames.
    14o consecutive patients treated . Diagnosis clinically (this seems unusual given patients were conservatively treated and those with major tendon end separations would be managed no differently). 4 weeks in pop (BK) non weight bear then 4 weeks in removable Patella-weight bear cast.
    3 complete re-ruptures & 5 partial re-ruptures.
    Over 80% very satisfied & the majority of the remainder satisfied with minor reservations.
    Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture
    Clin Orthop Relat Res. 2012 Jan; 470(1): 270–274
    A Patel , B Ogawa, T Charlton, D Thordarson
    Symptomatic DVT and PE identified by database review of 1172 cases treated by any means. Incidences of over 0.4% and over 0.3% reported respectively.
    Venous thromboembolism following prolonged cast immobilisation for injury to the tendo Achilles
    J Bone Joint Surg Br:2010 May ;92(5):646-50.
    B Healy, R Beasley, M Weatherall.
    An audit of 208 patients with the relevant injury revealed over 6% suffered the complication, only 1 patient receiving any thrombo-prophylaxis.
    Rupture of the Calcaneal tendon: Early and late management. Carden et al
    J Bone Joint Surg 1987 69-B) (3):417-20
    A cohort of over 100 patients treated by a single surgeon. Management was both operative and non-operatively and further subdivided into those treated within 48 hours of injury and those beyond. Just over 70 patients treated within 48 hours and the remainder later. Patients treated more than one week after rupture conservatively were noted to have reduced plantar-flexion power and operative management of this group is recommended (though numbers are of course low).

    Reference

    • orthoracle.com

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