DEFINITION

Rupture of the Achilles tendon is common.

More than 20% of acute injuries are misdiagnosed, leading to chronic or neglected ruptures.7

 

 

ANATOMY

 

The two heads of the gastrocnemius arise from the condyles of the femur, the fleshy part of the muscle extending to about the midcalf. As the muscle fibers descend, they insert into a broad aponeurosis that

contracts and receives the tendon of the soleus on its deep surface to form the Achilles tendon.11

 

The Achilles tendon is the thickest and strongest tendon in the body. About 15 cm long, it originates in the midcalf and extends distally to insert into the posterior surface of the calcaneus. It receives muscle fibers from

the soleus on its anterior surface throughout its length.11

 

PATHOGENESIS

 

The most common mechanism of injury is pushing off with the weight-bearing forefoot while extending the knee. Sudden unexpected dorsiflexion of the ankle or violent dorsiflexion of a plantarflexed foot may also result

in ruptures.8

 

Corticosteroids, fluoroquinolone use, tendon pathology, and poor vascularity of the Achilles tendon have been associated with rupture.8

NATURAL HISTORY

 

A delay in treatment of Achilles tendon rupture results in the formation of a discrete gap. The gap between ruptured tendon ends may fill with fibrous nonfunctional scar. Patients find walking and ascending stairs difficult and standing on tiptoes on the affected limb impossible.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients often give a history of feeling a blow to the posterior aspect of the leg and may describe an audible snap followed by pain and inability to bear weight.

 

In acute tendon ruptures, a gap in the Achilles tendon is usually palpable. In delayed presentation, edema may fill this gap, making palpation unreliable.

 

Active plantarflexion of the foot is usually preserved due to the action of the tibialis posterior and the long toe flexors.

 

The calf squeeze test, first described by Simmonds10 in 1957 but often credited to Thompson, is performed

with the patient prone and the ankles clear of the table. The examiner squeezes the fleshy part of the calf, causing deformation of the soleus and resulting in plantarflexion of the foot if the Achilles tendon is intact. The affected leg should be compared to the contralateral leg.

 

The knee flexion test is performed with the patient prone and the ankles clear of the table. The patient is asked to actively flex the knee to 90 degrees. During this movement, the foot on the affected side falls into

neutral or dorsiflexion and a rupture of the Achilles tendon can be diagnosed.9

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

The diagnosis of acute ruptures is usually a clinical one.

 

Plain lateral radiographs may reveal an irregular configuration of the fat-filled triangular space anterior to the Achilles tendon and between the posterior aspect of the tibia and the superior aspect of the calcaneus.

 

DIFFERENTIAL DIAGNOSIS

Ankle sprain

 

 

NONOPERATIVE MANAGEMENT

 

Acute ruptures may be managed conservatively in an equinus cast for 6 to 8 weeks before being converted to a functional brace.

 

Conservative management may result in tendon lengthening, thus altering function.1

 

SURGICAL MANAGEMENT

 

Percutaneous repair6 was originally described as a compromise between open surgery and conservative management. A percutaneous repair aims to provide the optimal functional outcome of open repair while decreasing the problems associated with it in terms of wound healing and skin breakdown. Recent studies suggest that minimally invasive surgery is less expensive, less time demanding, and it has similar outcome

compare to open repair in surgical management of acute Achilles tendon rupture.2,3 However, iatrogenic neurologic complications, such as sural nerve injury, are more frequent after percutaneous repair.

 

Preoperative Planning

 

 

Once the diagnosis is made, an assessment of general health and comorbidities should be performed. The preoperative functional status should be noted.

 

 

The skin quality and neurovascular status of the affected limb should be examined. The status of the sural nerve should be documented.

 

We recommend that the patient be maintained on deep venous thrombosis prophylaxis.

 

The procedure can be performed under general anesthesia or a local anesthetic, with a 50:50 mixture of 10 mL of 2% lignocaine hydrochloride (Antigen Pharmaceuticals Ltd, Roscrea,

 

98

Ireland) and 10 mL of 0.25% bupivacaine hydrochloride (Astra Pharmaceuticals Ltd, Kings Langley, England) instilled into an area of between 8 and 10 cm around the ruptured Achilles tendon.

Positioning

 

The patient is placed prone and a pillow is placed beneath the anterior aspect of the ankles to allow the feet to hang free.

 

 

The operating table is angled down 20 degrees cranially to reduce venous pooling in the feet and ankles. The affected leg is prepared with antiseptic and sterile draped. We do not use a tourniquet.

 

Local anesthetic infiltration is used. Instill a 50:50 mixture of 10 mL of 2% lignocaine hydrochloride (Antigen Pharmaceuticals) and 10 mL of 0.25% bupivacaine hydrochloride (Astra Pharmaceuticals) into an area 8 to 10 cm around the ruptured Achilles tendon.

 

Approach

 

Previous approaches such as those described by Ma and Griffith6 using three medial and three lateral stab incisions have been abandoned in light of the relatively increased incidence of sural nerve entrapment.

 

We will present the surgical technique we usually employ.

 

TECHNIQUES

• Percutaneous Repair of Acute Achilles Tendon Rupture

 

A 1-cm transverse incision is made over the defect using a no. 11 blade.

 

Four longitudinal stab incisions are made lateral and medial to the tendon, 6 cm proximal to the palpable defect.

 

Two further longitudinal incisions on either side of the tendon are made 4 to 6 cm distal to the palpable defect.

 

 

 

TECH FIG 1 • A. A 9-cm Mayo is threaded with two double loops of no. 1 Maxon and passed transversely

between the proximal stab incisions through the bulk of the tendon. B. Another double loop of Maxon is then passed between the distal stab incisions through the tendon. C. The double loop of Maxon is passed, in turn, through the tendon and out of the transverse incision starting distal to the transverse passage. D. A full plaster-of-Paris cast is applied in the operating room with the ankle in physiologic equinus. The cast is split on both medial and lateral sides to allow for swelling.

 

 

Forceps are then used to mobilize the tendon from beneath the subcutaneous tissues.

 

A 9-cm Mayo needle (BL059N, #B00 round-point spring eye, B Braun, Aesculap, Tuttlingen, Germany) is threaded with two double loops of no. 1 Maxon (Tyco Healthcare, Norwalk, CT), and this is passed transversely between the proximal stab incisions through the bulk of the tendon (TECH FIG 1A).

 

The bulk of the tendon is surprisingly superficial. The loose ends are held with a clip.

 

 

99

 

Each of the ends is then passed, in turn, distally from just proximal to the transverse Maxon passage through the bulk of the tendon to pass out of the diagonally opposing stab incision.

 

A subsequent diagonal pass is then made to the transverse incision over the ruptured tendon. To prevent entanglement, both ends of the Maxon are held in separate clips.

 

This suture is then tested for security by pulling with both ends of the Maxon distally.

 

Another double loop of Maxon is passed between the distal stab incisions through the tendon (TECH FIG 1B) and in turn through the tendon and out of the transverse incision starting distal to the transverse passage (TECH FIG 1C).

 

The ankle is held in full plantar flexion, and, in turn, opposing ends of the Maxon thread are tied together with a double throw knot, and then three further throws before being buried using the forceps.

 

A clip is used to hold the first throw of the lateral side to maintain the tension of the suture.

 

We use 3-0 Vicryl (Ethicon, Somerville, NJ) suture to close the transverse incision and Steri-Strips (3M Health Care, St Paul, MN) to close the stab incisions. A nonadherent dressing is applied.

 

A full plaster-of-Paris cast is applied in the operating room with the ankle in physiologic equinus.

 

The cast is split on both medial and lateral sides to allow for swelling (TECH FIG 1D).

 

 

PEARLS AND PITFALLS

 

Tourniquet ▪ Avoiding the use of the tourniquet allows identification and hemostasis of bleeding points, reducing the incidence of postoperative hematoma.

 

 

POSTOPERATIVE CARE

 

 

Patients are discharged on the same day of the operation. The neurovascular status of the limb is assessed.

 

After assessment by a physiotherapist, making sure that the patient is safe and comfortable in the cast, the patient can be discharged.

 

The full cast is retained for 2 weeks, and patients are allowed to bear weight as comfort allows. During the period in the cast, patients are advised to perform gentle isometric contractions of the gastrocnemius-soleus complex.

 

At 2 weeks, patients are reviewed as outpatients, the cast is split, and the wounds are inspected. An anterior splint is worn with the foot in plantarflexion for a further 4 weeks.

 

Patients are advised to mobilize with partial weight bearing initially, increasing to weight bearing as able by 4 weeks.

 

The splint is then removed and physiotherapy follow-up for gentle mobilization is arranged. Light weight-bearing exercise can be started 2 weeks after cast removal, and the patient should be fully weight bearing by 10 weeks.

 

 

OUTCOMES

Lim et al,5 in a randomized controlled trial, advocated percutaneous repair over open surgical techniques after finding no significant differences in functional results, a lower infection rate with the percutaneous repair, and a subjectively more acceptable cosmetic appearance of the percutaneous operative site.

A recent review showed similar clinical, functional outcomes after minimally invasive surgery for Achilles tendon ruptures compared to open repair.3 Furthermore, the number of complications that occurred after percutaneous repair was lower than after open surgery.3

In a previous work, 31 patients who underwent percutaneous repair in our tertiary referral center between

2001 and 2003 have been reviewed.12 Eleven patients (35.5%) received general anesthesia and 20 (64.5%) had local anesthesia. The average length of cast time was 5.97 weeks. One (3.2%) patient sustained a major complication, a small pulmonary embolism, which was managed successfully with warfarin. There were no reruptures, and six (19.4%) patients had minor wound complications.

More recently, this percutaneous technique showed satisfactory outcome in terms of strength and return to preoperative level of sport activity.4

 

 

COMPLICATIONS

Early complications: sural nerve damage and hematoma

Intermediate complications (<6 weeks): superficial and deep wound infections Late complication (>6 weeks): rerupture

 

 

ACKNOWLEDGMENT

 

We are grateful to Nicholas A. Ferran, MD, PhD, and Ansar Mahmood, MD, who coauthored the first edition of this chapter.

REFERENCES

1. Bohnsack M, Ruhmann O, Kirsch L, et al. Surgical shortening of the Achilles tendon for correction of elongation following healed conservatively treated Achilles tendon rupture [in German]. Z Orthop Ihre Grenzgeb 2000;138:501-505.

    

    

2. Carmont MR, Heaver C, Pradhan A, et al. Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair. Knee Surg Sports Traumatol Arthrosc 2013;21:1361-1368.

    

    

3. Del Buono A, Volpin A, Maffulli N. Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review. Br Med Bull 2014;109:45-54.

    

    

4. Guillo S, Del Buono A, Dias M, et al. Percutaneous repair of acute ruptures of the tendon Achillis. Surgeon 2013;11:14-19.

    

    

   00

    

5. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon—a prospective randomized controlled study. Foot Ankle Int 2001;22:559-568.

    

    

6. Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res 1977;(128):247-255.

    

    

7. Maffulli N. Clinical tests in sports medicine: more on Achilles tendon. Br J Sports Med 1996;30:250.

    

    

8. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81(7):1019-1036.

    

    

9. Matles AL. Rupture of the tendo Achilles: another diagnostic sign. Bull Hosp Joint Dis 1975;36:48-51.

    

    

10. Simmonds FA. The diagnosis of the ruptured Achilles tendon. Practitioner 1957;179:56-58.

     

     

11. Williams PL. Gray's Anatomy, ed 38. Edinburgh: Churchill Livingstone, 1995.

     

     

12. Young J, Sayana MK, McClelland D, et al. Percutaneous repair of acute rupture of Achilles tendon. Tech Foot Ankle Surg 2006;5: 9-14.