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Achilles Tendon Rupture

The incidence of achilles ruptures is increasing, probably due to the increase in sports and exercise amongst an older population.

Whether its treated surgically or conservatively, the recovery is prolonged and it will take 8-10 months to return to full activity and sports and over a year to reach maximum recovery.    The goal of treatment is to achieve maximum function in the calf muscles and this requires intensive input from physiotherapy and from the patient to achieve this.

We know from the original papers by Mason & Allen in 1948, that tendons heal quickest and strongest if they are immobilised for a short period and then mobilised within a protected environment.  This is the focus of current achilles rupture management.   We also know that early weightbearing is not detrimental if the ankle is protected in plantarflexion.

It is important to know the severity of the injury and ultrasound is the investigation of choice – it will confirm the site of rupture and also the presence of any gap in the tendon ends. Ruptures at the proximal muscul0tendinous junction do not require surgery and should be treated conservatively (surgery may still be indicated in professional athletes).  Ruptures or avulsions at the distal end usually require surgery as there is often a large gap. This will require open surgery (see achilles avulsion).

Most ruptures occur in the midportion  6-7cm above the insertion and the ultrasound will confirm most importantly if the tendon ends appose in plantarflexion.  Recent studies have shown that little or no benefit with surgery in patients where there is a gap <5mm and these can be successfully treated in a well structured rehabilitation programme with protection in an equinus cast or boot, with reducing equinus over several weeks.   If there is a significant gap >5mm then, in my opinion, surgery is required although some surgeons use >10mm gap as the cut off.

In professional athletes or where maximal achilles function is essential for work, I recommend surgical repair – long term function studies have confirmed significant benefits in plantarflexion torque with surgery.

Ideally, the surgery should be performed using minimally invasive techniques – these have been shown to have significantly lower risks of wound and infective complications, when compared to open surgery.   The technique described here is one method – there are others that use jigs to guide the suture placement (Achillon and PARS devices)

Readers will also find the following OrthOracle techniques of interest:

Achilles tendon rupture: Integra Achillon percutaneous repair.

Achilles tendon rupture: Open repair technique.

Achilles Reconstruction :Flexor Hallucis Longus tendon transfer using Arthrex Biotenodesis screw

Achilles avulsion: Reattachment using an Arthrex Biocomposite anchor.

Grassi et al. Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery. J Bone Joint Surg Am. 2018

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(see also: Achilles Tendonitis)

Discussion

  • ruptures typically occur after age 30, more often in people beyond middle age;
  • rupture at musculous tendinous junction occurs most often in young people, but ruptures near the calcaneus also occur;
    • inciting event may be related to atrophy of the soleus muscle, and commonly occur in weekend athletes;
    • in 5-33% of patients there will be a prodromal incident of pain several days beforhand;
    • mechanism usually involves eccentric loading on a dorsiflexed ankle with the knee extended (soleus and gastroc on maximal stretch);
  • unlike flexor tendons in the hand, the Achilles tendon has no true synovial sheath, but rather is covered only by a paratenon;
    • hence, exogenous healing (from synovial fluid) would not be expected to occur;

inciting causes

  • consider systemic conditions such as gout or hyperparathyroidism (esp with pure avulsion injury);
  • inquire about previous steroid injections / injections of steroids into or around the Achilles tendon may provoke rupture and should generally be avoided;
  • flouroquinolones may also contribute to tendon rupture;

Exam Findings »

Radiographic Studies

Non Operative Rx »

Operative Repair

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

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discussion

  • most indicated in a younger patient w/ a clinically displaced rupture;
  • may allow earlier return to sports, earlier return of muscle power, and a lower re-rupture rate as compared to non operative
  • main complication is wound slough;

positioning

  • place the tourniquet on the leg in the supine position, before turning the patient prone (its difficult to place the tourniquet in the prone position);
  • before prepping, note the resting equinus position of the uninjured leg (and attempt to reproduce this equinus position during surgery);
  • if a surgical assistant is not available, position the patient so that the dorsum of the forefoot remains on the table (not dangling off the table), so that the foot can be held in equinus during the tendon repair;

incision

  • longitudinal incision is made just medial to achilles tendon;
  • a medially placed incision may be less likely to slough from the pressure that the repaired tendon exerts on the overlying skin;
    • additionally a medially placed incision is less likely to develop postop adhesions;
  • a laterally placed incision may injure the sural nerve and the lesser saphenous venous plexus;

para-tenon

  • w/o creating a flap, the incision is carried down to the para-tenon;
  • some surgeons will attempt to cut the paratenon straight over the tendon (as opposed to the the medial side in line with the incision);

evaluate tendon defect

  • identify the level of the rupture of the Achilles tendon;
  • attempt to identify the plantaris tendon;
  • mobilize the proximal Achilles tendon by sweeping a finger circumferentially aroung the tendon border (thus breaking up adhesions);
  • using non-traumatic clamps, match the ends of the ruptured tendon to achieve optimal length;

suture repair

fascial augmentation

  • gastrocnemius aponeurosis:
    • make rectangular 1-2 cm wide by 8 cm long flap from proximal tendon and gastroc aponeurosis which is raised to with in 3 cm of rupture site;
      • immediately beneath the gastroc fascia, the surgeon will note the soleus muscle;
    • proximal flap edge is then flipped distally across the repair site and sutured down;
    • the fascial defect is closed with interrupted sutures;
    • stated advantageous include less adhesion formation and a stronger repair;
  • plantaris tendon augmentation:
    • can be used to augment the repair by weaving it across the repair site;
    • it can be left attached either proximally or distally;
    • alternatively plantaris tendon can be fanned out to make a 2.5 cm membrane that is then sutured around the repair site;
  • attempt to close paratenon, especially over the tendon repair site; this is important both for healing and prevention of adhesions;

post operative care »

Complications

Deep Infection and Wound Breakdown

(see also: prevention of infection)

Wound Vac Therapy »

(followed by STSG)

Chronic Tear

The Flexor Hallucis Longus transfer for Achilles reconstruction is a straight-forward and effective operation for salvaging various situations which have resulted in a deficient and de-functioned Achilles tendon.

The flexor hallucis longus tendon is easily accessed sitting just anterior to the Achilles tendon and can be safely harvested  as long as care is taken to identify and avoid the posterior tibial neuro-vascular bundle. It has not been my experience in performing this procedure for over 15 years that any more than a single incision is required to access and harvest adequate length of the FHL for reconstruction. If the tendon is slightly too short for a bone anchor it can be woven into the native Achilles insertion and sutured.

The Arthrex Biotenodesis screw is a useful implant to anchor the harvested tendon into the calcaneus, though the tendon can be woven into the native Achilles insertion also. The key is appropriate tensioning of the transfer.

Despite the slightly more involved nature of surgery compared to primary Achilles repair  the period of immobilisation and recovery and outcome are little different.

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This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

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References