Open Achilles Tendon Repair

Abstract

Background:An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury—and the resulting open repair—are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible.Description:Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion.Alternatives:Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport1,2.Rationale:Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair3. Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness)2. Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment.Expected Outcomes:Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al.4, 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no reruptures. In a recent meta-analysis by Meulenkamp et al.5, the authors found that operative repair of Achilles tendon rupture was associated with a reduced risk of rerupture compared with primary immobilization (i.e., conventional cast i...

Postoperative Return to Play and the Role of Imaging

“…35 Despite the Achilles tendon having the greatest tensile strength in the human body, it is also one of the most common tendons to rupture, often during sport activities. 5,[38][39][40][41] Pathophysiology of Achilles tendon rupture is multifactorial, with increased risk associated with certain medications, such as fluoroquinolone antibiotics, corticosteroids, hormone replacement, and oral contraceptives, as well as peripheral vascular disease and inflammatory disorders. 9,36,39 In addition, internal factors such as tendinosis and external factors related to tendon workload contribute to the development of tendon rupture.…”

“…37 Current literature supports operative repair of the ruptured Achilles tendon in athletes because it was shown to improve performance, particularly in the setting of jumping, muscle endurance, and muscle strength. 35,37,40,43 In addition, the surgically repaired tendon has a decreased risk of rerupture and an accelerated return to sport compared with nonoperative intervention. 31,37,40,43 Multiple operative interventions for Achilles repair are available, including open and minimally invasive procedures.…”

“…35,37,40,43 In addition, the surgically repaired tendon has a decreased risk of rerupture and an accelerated return to sport compared with nonoperative intervention. 31,37,40,43 Multiple operative interventions for Achilles repair are available, including open and minimally invasive procedures. Both open and minimally invasive repairs involve suturing the tendon back together; however, whereas in an open repair the tendon fibers can be sutured directly together, particularly if the tear is small, minimally invasive repair does not involve a direct end-to-end repair.…”

“…35 37 40 43 In addition, the surgically repaired tendon has a decreased risk of rerupture and an accelerated return to sport compared with nonoperative intervention. 31 37 40 43…”

Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture—15-Year Follow-Up

“…Surgical Procedure: The patient was positioned prone in standard fashion for an open Achilles approach 10 . A 25-cm incision was made along the prior incision scar on the posteromedial border of the Achilles, extending proximally to the midcalf level.…”