DEFINITION

Achilles tendon ruptures usually occur 3 to 4 cm above the calcaneal tuberosity. Although most injuries are “complete” ruptures, “partial” injuries have been described.

 

 

ANATOMY

 

The Achilles tendon is about 9 cm long and 0.9 cm in diameter.

 

The proximal part is composed of the gastrocnemius and soleus tendons.

 

The distal portion inserts onto the posterior aspect of the tuberosity of the calcaneus.

 

The Achilles tendon is surrounded by the paratenon, a delicate envelope that contributes to tendon vascularization.

 

There is an area of poor vascularity located between 2.5 and 5 cm above the calcaneal tuberosity.

 

PATHOGENESIS

 

Rupture of the Achilles tendon is a common injury among high-level athletes, recreational sports enthusiasts, or even sedentary individuals.

 

 

Rupture of the Achilles tendon usually occurs during forceful dorsiflexion of the ankle. Patients often describe hearing or feeling a “pop” in the back of their ankle.

 

Intratendinous degeneration can be found histologically.

 

Association with cortisone and fluoroquinolone use has been demonstrated.

 

This is typically a lesion of middle age, with peak incidence during the third and fourth decades.

 

NATURAL HISTORY

 

There is a great deal of controversy concerning the treatment of an acute rupture of the Achilles tendon.

 

Conservative treatment is found to have a higher rate of tendon rerupture and loss of strength because the tendon heals in an elongated position.

 

The major factor motivating surgeons to use a nonoperative approach appears to be avoiding the wound complications that occur with an operative repair.

 

An increasing number of reports in the literature have tended to favor operative treatment of an acute rupture of the Achilles tendon.

 

The exact type of operative procedure and the postoperative regimen remain controversial. Mini-invasive

techniques are associated with a lower complication rate.

 

If soft tissue complications are avoided, excellent functional results and full return to previous activity can be expected.

 

PHYSICAL FINDINGS

 

 

Physical examination reveals moderate swelling about the posterior aspect of the ankle. Patients are usually able to walk, although with moderate pain.

 

With the patient prone, spontaneous excess dorsiflexion of the involved ankle is noted.

 

In most cases, a tender defect (“soft spot”) can be palpated in the Achilles tendon between 2.5 and 5 cm proximal to its insertion into the calcaneal tuberosity.

 

The Thompson squeeze test is positive.

 

Patients have difficulty walking on their toes or rising up on their heels.

 

IMAGING AND DIAGNOSTIC STUDIES

 

History and physical examination are sufficient to confirm the diagnosis.

 

 

Because these injuries occur in a traumatic setting, plain radiographs of the ankle are strongly advised. There have been many reports of associated ankle fractures (medial malleolus).

 

Calcaneal (tuberosity) avulsion will appear on the lateral view.

 

Ultrasound and magnetic resonance imaging (MRI) are not required for the diagnosis of Achilles tendon rupture but may be of value when the diagnosis is questionable.

 

DIFFERENTIAL DIAGNOSIS

Ankle sprain Ankle fracture

Tennis leg (gastrocnemius tear) Acute paratenonitis

Calcaneal (tuberosity) avulsion Plantaris tendon rupture

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative treatment of acute Achilles tendon ruptures involves prolonged immobilization.

 

Prolonged immobilization is associated with musculoskeletal changes (atrophy), increased time necessary for rehabilitation, and delayed return to work and preinjury activities.

 

 

In randomized studies, the rerupture rate has been found to be much higher in the nonoperative group. However, nonoperative treatment avoids surgical complications.

 

Nonoperative treatment should be considered in elderly patients with limited functional expectations, patients with significant tobacco or alcohol addictions, patients receiving chronic cortisone treatment, patients with vascular disease, and patients with severe comorbidities such as renal failure.

 

Indications and Contraindications

75

 

The indication for this technique is an acute (<3 weeks) Achilles tendon rupture, occurring 2 to 7 cm above the tuberosity of the calcaneus.

 

 

Over 90% of ruptures of the Achilles tendon occur in the area 2 to 8 cm above the calcaneal tuberosity.

 

We believe that ruptures occurring more than 8 cm above the tuberosity (muscular ruptures) can be treated nonoperatively and ruptures occurring less than 2 cm from the tuberosity necessitate fixation directly to bone.

 

Contraindications include chronic rupture greater than 3 weeks in duration, previous local surgery, steroid use, open ruptures and lacerations greater than 6 hours in duration, complex open ruptures with soft tissue defects, and ruptures not occurring between 2 and 8 cm above the tuberosity of the calcaneus.

 

SURGICAL MANAGEMENT

Preoperative Planning

 

 

Plain films should be reviewed for fracture, avulsion, and calcific tendinopathy. All imaging studies are reviewed.

 

An examination under anesthesia should be performed before positioning the patient to reconfirm the side of injury.

 

Positioning

 

 

The patient is placed prone on the operating table. A tourniquet is applied around the upper thigh.

 

Both legs are included in preparation and draping to compare Achilles tendon tension and spontaneous plantarflexion intraoperatively.

 

 

Plastic draping is not used (the technique involves percutaneous steps). Patients receive antibiotic prophylaxis.

Instrumentation

 

The Achillon (Integra LifeScience, Plainsboro, NJ) was designed by Matthieu Assal and is made of either a rigid polymer or stainless steel (FIG 1).

 

It is designed to guide the passage of the sutures.

 

It is composed of a pair of internal branches connected to a pair of external branches, with each branch having a line of apertures at the same level to allow easy and accurate passage of the sutures through all four branches.

 

The two internal branches are at an 8-degree angle to each other, following the V-shaped anatomic form of the tendon.

 

A micrometric screw allows for varying the opening of the branches according to tendon morphology.

 

A straight needle loaded with a suture is passed through the device, soft tissues and tendon. A cap for the needle facilitates applying pressure to the end of the needle.

 

 

 

 

FIG 1 • The Achillon instrument, with a straight needle and suture passed through one of the levels of holes.

 

TECHNIQUES

• Open Repair Illustrated

Exposure

Palpate the site of injury, represented by the gap or soft spot (TECH FIG 1A).

The incision is paratendinous and medial (TECH FIG 1B), beginning at the soft spot and extending about

2.0 cm proximally.

Gently retract the skin and subcutaneous tissue with hooks and identify the paratenon (TECH FIG 1C). Carefully open the sheath and tag each edge with a stay suture (TECH FIG 1D).

Identify both stumps of the ruptured tendon (TECH FIG 1E) and carefully note the exact site of rupture.

Introducing the Achillon

Introduce the Achillon in the closed position under the paratenon in a proximal direction, holding the tendon stump with a small clamp under the instrument (TECH FIG 2A).

 

 

The tendon stump is located between the two internal branches (TECH FIG 2B).

 

As the instrument is introduced, progressively widen it, holding the tendon stump firmly with the clamp.

 

Confirm the position of the guide by external palpation; you should feel the tendon between the central (internal) branches of the instrument.

Suturing

 

Pass three sutures from lateral to medial, usually beginning with the most proximal hole of the instrument (TECH FIG 3A,B).

 

 

Hold the end of each suture with a small clamp to keep them separate from each other. Slowly withdraw the instrument while progressively closing the branches (TECH FIG 3C).

 

This maneuver results in the sutures sliding from an extracutaneous position to a peritendinous position, and thus the tendon itself is the only tissue held by the sutures (TECH FIG 3D).

 

Apply traction to the three suture pairs to ensure they are firmly anchored in the tendon and individually clamp them to prevent any confusion.

 

76

 

 

 

TECH FIG 1 • The skin incision begins at the gap or soft spot (A), paratendinous and medial, and extends 1.5 to 2 cm proximally (B). C. The sheath is opened longitudinally in the midline. D. A stay suture is placed. E. Forceps grasp the proximal tendon stump.

 

 

77

 

 

 

TECH FIG 2 • A,B. Introduction of the instrument proximally under the paratenon.

 

 

 

TECH FIG 3 • A. The first needle is introduced. B. All three sutures in the proximal tendon. The instrument is withdrawn (C), bringing the sutures from an extracutaneous to a peritendinous position (D). Next, the exact same sequence performed on the distal stump. (continued)

 

 

78

 

 

 

TECH FIG 3 • (continued) E. The instrument is introduced under the tendon sheath and pushed until it touches the calcaneus. F. The sutures organized for tightening. G. Tendon reduction is performed under direct vision, confirming apposition of the tendon ends.

 

 

Perform the same sequence on the distal stump: Introduce the instrument under the tendon sheath and push it until it touches the calcaneus (TECH FIG 3E).

 

All the sutures are now organized for tightening (TECH FIG 3F), which is carried out with corresponding pairs, and the tendon reduction is under direct visual control (TECH FIG 3G).

 

If it is difficult to ascertain tendon length and reduction because the ends are too frayed, compare the tendon tension to the opposite leg.

Closure

 

 

Close the tendon sheath and then the skin with intradermal sutures (TECH FIG 4). No drain is used.

 

Apply a splint holding the ankle in 30 degrees of flexion before moving or waking up the patient.

 

 

 

TECH FIG 4 • Closure of the skin with intradermal sutures.

 

 

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• Open Repair in Intraoperative Photographs

Approach and Identification of Ruptured Tendon Ends

 

Mini-open incision (TECH FIG 5A)

 

Make a longitudinal skin incision about 2 cm long at the level of the rupture.

 

The incision is longitudinal in the event the procedure has to be converted to a full open procedure.

 

Divide the paratenon to gain control of the ruptured tendon ends (TECH FIG 5B).

 

The plantaris tendon may occasionally be intact despite complete Achilles tendon rupture (TECH FIG 5C).

 

Tag the two tendon ends with suture (TECH FIG 5D,E).

Placing Permanent Sutures in Proximal Aspect of the Ruptured Tendon

 

Using the proximal tag sutures, apply tension to the proximal tendon stump.

 

 

 

TECH FIG 5 • A. Mini-open longitudinal incision directly over tendon rupture. B. Paratenon is divided to gain access to tendon ends. C. The plantaris tendon may remain intact despite complete Achilles tendon rupture. D. Tag sutures are placed on the mobilized tendon ends. E. Tension is applied to tag sutures, approximating the tendon ends.

 

 

Place retractors within the paratenon to define the interval between the tendon and the paratenon.

 

Advance the Achillon device within the paratenon on the medial and lateral aspects of the tensioned proximal tendon (TECH FIG 6A,B).

 

Typically, the tendon is palpable between the arms of the Achillon device.

 

In succession from closest to farthest from the rupture, pass three sutures through the tensioned proximal tendon (TECH FIG 6C-F).

 

By retracting the Achillon device distally back into the wound, secure the sutures in the tendon, within the paratenon, and exiting within the wound (TECH FIG 6G,H).

 

Tension must be placed on the sutures before proceeding to the next step to ensure the sutures are properly anchored in the proximal tendon (TECH FIG 6I).

 

If the sutures pull out, repeat the three aforementioned steps, with careful palpation to be sure that the tendon is indeed between the arms of the Achillon device.

 

80

 

 

 

TECH FIG 6 • A. The Achillon device is advanced within the paratenon. B. Longitudinal tension placed on the tag suture while advancing the Achillon device facilitates optimal positioning of the tendon between the two arms of the Achillon device. C. The suture closest to the rupture is inserted first. Tension is maintained on the tag suture. D. The second suture is passed through the tendon. E. The third suture is passed.

Tension is still maintained on the tag suture, and the tendon is centered between the two arms of the Achillon device that are within the paratenon. F. All three sutures are passed through the proximal tendon and organized. G,H. By retracting the device from the wound, the three sets of sutures remain in the tendon, are within the paratenon, and exit at the wound. I. Longitudinal traction is placed on the sutures to ensure that they are secure within the proximal tendon.

 

 

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Placing Permanent Sutures in Distal Aspect of the Ruptured Tendon

 

This is essentially the mirror image of placing sutures in the proximal tendon.

 

With distal ruptures, the Achillon device must be advanced as close to the Achilles insertion on the calcaneus as possible to optimize the sutures' purchase in tendon.

 

Advance the Achillon device's inner arms on either side of the Achilles tendon, within the paratenon (TECH FIG 7A).

 

Palpate to be sure that the tendon is indeed between the two arms of the Achillon device.

 

Place the three sutures (similar to those in the proximal tendon), from closest to farthest from the rupture, into the distal tendon, with tension applied to the tag sutures (TECH FIG 7B-E).

 

Retract the Achillon device from the wound, thereby bringing the three sutures within the paratenon and into the wound, ready for repairing the rupture (TECH FIG 7F).

 

To ensure that the purchase of the sutures in the distal tendon is satisfactory, apply forceful tension to the sutures.

 

Tension should plantarflex the ankle (TECH FIG 7G).

 

Should the sutures pull out, repeat the steps described earlier so that acceptable purchase of the sutures in the distal tendon is achieved. In our opinion, palpation of the tendon between the arms of the Achillon device is helpful.

 

 

 

TECH FIG 7 • A. The Achillon device is advanced within the paratenon on the medial and lateral aspects of the distal tendon. B-E. The three sutures are placed in the distal tendon and organized. F. The Achillon device is retracted from the wound so that the three sutures remain within the tendon, are within the paratenon, and exit at the wound. G. Longitudinal traction ensures that the sutures are secure within the distal tendon. Note the plantarflexion of the ankle with tension on the sutures.

 

Tendon Repair

 

Approximate the two tendon ends by tensioning the sutures (TECH FIG 8A).

 

The sutures must be carefully organized so that corresponding sutures are secured to one another.

 

Passive plantarflexion of the ankle with a bump placed under the dorsum of the foot or maintained by an assistant takes tension off the tendon during repair.

 

Secure the two sets of sutures closest to the rupture to one another first.

 

With tension maintained on one side, secure the other side with a surgeon's knot (TECH FIG 8B).

 

Then secure the other side, applying tension first to remove residual slack in the suture (TECH FIG 8C).

 

 

 

Repeat the suture technique described for the initial set of sutures for the other sets (TECH FIG 8D). Secure the intermediate set of sutures to one another, followed by the sets farthest from the rupture. If the sutures more distant from the rupture are overtensioned during the repair, then the tension

gained with the

 

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previously secured sutures is forfeited. Therefore, overtensioning of each successive set of sutures is unnecessary.

 

With the opposite, uninjured extremity prepared into the operative field, the resting tension of the repair may be compared to what is deemed physiologic (TECH FIG 8E).

 

Setting the resting tension of the repair slightly greater than that of the contralateral extremity is acceptable and, in our opinion, preferred.

 

Avoid undertensioning of the repair.

 

As for flexor tendon repairs for the hand, we recommend reinforcing the repair with additional sutures directly at the rupture (TECH FIG 8F).

 

In our opinion, this is important because the mini-open technique described earlier only serves the function of an internal splint. When the repair site is directly palpated after repair with only the three sets of sutures, invariably, there is mostly suture at the repair site and relatively little collagen.

 

 

 

TECH FIG 8 • A. The ruptured tendon ends are approximated by tensioning both sets of sutures. B. One side of the corresponding sutures closest to the rupture is tied. Tension should be maintained on the other side of this set of sutures. C. After removing slack in the suture, the other side of this first set of sutures is tied. D. The second and third set of sutures are secured. Overtensioning of each successive set of sutures should be avoided because this will cause the previous set to lose its tension. E. The resting tension of the repair should match that of the other uninjured extremity.

Preferably, the tension should be slightly greater in the repair. F. The repair is reinforced with a single running or multiple interrupted sutures directly at the rupture.

 

 

We routinely perform this reinforcement with a running, absorbable suture.

 

This not only reinforces the tendon repair but tends to bring more tendon collagen directly to the repair site.

 

Place the running or alternatively multiple interrupted sutures circumferentially at the repair site.

Closure

 

Repair the paratenon and fascial layer over the tendon to a “water-tight” closure (TECH FIG 9A).

Reapproximate the subcutaneous layer and skin to a tensionless closure (TECH FIG 9B,C).

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TECH FIG 9 • A. The paratenon and fascial layer are reapproximated. B,C. The subcutaneous layer and skin are reapproximated to a tensionless closure.

 

 

 

PEARLS AND PITFALLS
	Ensure that ▪ Palpate the tendon between the Achillon device arms during suture insertion. the tendon is between the arms of the Achillon device.     Gain ▪ Use tag sutures in the ruptured tendon ends to apply tension while advancing maximum the Achillon device and while passing sutures through the tendon. purchase of the sutures in the tendon.     Organize the ▪ Use three different colors for the sutures on either side of the repair to facilitate sutures. coordinating corresponding sutures for the repair.     Ensure that ▪ Apply tension to the sutures after they have been passed through the tendon

 

 

	the sutures and have been organized within the paratenon; if they should pull out, then they are indeed will need to be passed again. secured in the tendon ends before repair.     Optimal ▪ In our experience, setting the tension slightly greater than the opposite tensioning of extremity's physiologic resting tension is appropriate and leads to an optimal the repair outcome.     Assess the ▪ Although mini-open, the tendon ends may be assessed through the limited rupture approach. Occasionally, shear patterns of the rupture are not amenable to this pattern. technique and a more traditional open technique is warranted. We therefore recommend that the mini-open technique be performed through a short longitudinal incision that can easily be extended if necessary.

 

 

POSTOPERATIVE CARE

 

Low-molecular-weight heparin (subcutaneous administration) is used to prevent deep vein thrombosis for 3 weeks postoperatively.

 

Our early functional rehabilitation program, carefully supervised by the physical therapist, is divided into four stages.

 

For the first 2 weeks, patients are allowed partial weight bearing (30 to 45 pounds) and maintained in the splint full time.

 

Then, gentle ankle range of motion (flexion and extension) is begun as well as thigh muscle exercises and the use of a stationary bicycle.

 

The goal is to reach a neutral ankle position by the end of the third week.

 

After 3 weeks, full weight bearing is allowed with continuous use of the protective splint.

 

At the end of 8 weeks, the splint is discontinued and weight bearing is allowed without any external support.

 

A more intensive program of ankle range of motion, stretching, and isometric and proprioceptive exercises is instituted.

 

Jogging is allowed at 3 months and more demanding sports at 5 months.

 

 

Table 1 Concentric Peak Torque Measured with Isokinetic Dynamometry in 50 Patients

30

111.4 ± 19

118.9 ± 30

 

84

 

 

Angular Velocity (deg/s)	Mean Torque (Nm ± SD)
	Injured Side Unaffected Side

60 95.4 ± 19 101.3 ± 25

 

 

 

OUTCOMES

This limited open procedure with use of the Achillon instrument provides the advantage of an open repair but avoids the soft tissue problems associated with open repair.

We published a prospective multicenter study in 2002 including 82 patients. Results showed no wound healing problems and no infections. No patient noted a sensory disturbance in the sural nerve distribution. All patients returned to their previous professional or sporting activities. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 96 points (range, 85 to 100 points).

Complications occurred in three patients. Two of them were noncompliant and removed the orthosis within the first 3 weeks postoperatively, thus disrupting the repair by a new injury. One patient fell 12 weeks after the surgery and sustained a rerupture. All three new injuries were repaired with an open surgical procedure.

Isokinetic results: The concentric peak torque was performed with the ankle in plantarflexion at 30 and 60 degrees per second of angular velocity, after correction for dominance. There was no significant difference between the injured and uninvolved sides (Table 1). Endurance testing at 120 degrees per second also revealed no difference between sides.

Three recent reports describe similar excellent results using the exact surgical technique and Achillon instrument, thus providing further confirmation of its important role in the repair of acute Achilles tendon ruptures.

 

COMPLICATIONS

Disruption of the repair related to the patient's noncompliance with the rehabilitation protocol (before the third month postoperatively)

Rerupture of the healed Achilles tendon (after the third month postoperatively) Sural nerve injury

Infection

Deep venous thrombosis

 

 

SUGGESTED READINGS

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2. Assal M, Stern R, Peter R. Fracture of the ankle associated with rupture of the Achilles tendon: case report and review of the literature. J Ortho Trauma 2002;16:358-361.

    

    

3. Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures: a comparative study. Am J Sports Med 1990;18:188-195.

    

    

4. Calder JD, Saxby TS. Independent evaluation of a recently described Achilles tendon repair technique. Foot Ankle Int 2006;27: 93-96.

    

    

5. Cetti R, Christensen SE, Ejsted R, et al. Operative versus nonoperative treatment of Achilles tendon rupture: a prospective randomized study and review of the literature. Am J Sports Med 1993;21: 791-799.

    

    

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8. Haji A, Sahai A, Symes A, et al. Percutaneous versus open tendo Achillis repair. Foot Ankle Int 2004;25:215-218.

    

    

9. Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. J Bone Joint Surg Br 1995;77:60-63.

    

    

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12. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036.

     

     

13. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med 1995;23:392-395.

     

     

14. Rippstein P, Easley M. “Mini-open” repair for acute Achilles tendon ruptures. Tech Foot Ankle Surg 2006;5:3-8.

     

     

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