OPEN REPAIR OF ACHILLES TENDON RUPTURE

Open repair of acute Achilles tendon ruptures remains the gold standard of operative treatment, especially
for athletic individuals, because of the historically low rate of reruptures, high rate of return to sports, and
decreased complication rates with newer techniques. Advocates of open repair argue that Achilles tendon
injuries often result in complex obliquely oriented tears that cannot be adequately apposed and repaired with
percutaneous of mini-invasive techniques.

OPEN REPAIR OF ACHILLES TENDON RUPTURE — KRACKOW ET AL.

■ With the patient prone, make a posteromedial incision approximately 10 cm long about 1 cm medial to
the tendon and ending proximal to where the shoe counter strikes the heel.
■ Sharply dissect through the skin, subcutaneous tissues, and tendon sheath. Reflect the tendon sheath with
the subcutaneous tissue to minimize subcutaneous dissection.

■ Approximate the ruptured ends of the tendon with a 2-0 nonabsorbable suture.
■ Check the repair for stability after the sutures are tied.
■ Close the peritenon and subcutaneous tissues with 4-0 absorbable sutures.
■ Close the skin, and apply a sterile dressing and a posterior splint or short-leg cast with the foot in gravity equinus.

OPEN REPAIR OF ACHILLES TENDON RUPTURE — LINDHOLM

■ With the patient prone, make a posterior curvilinear incision extending from the midcalf to the
calcaneus.
■ Incise the deep fascia in the midline and expose the tendon rupture.

■ Debride the ragged ends of the tendon and appose them with a box type of mattress suture of heavy nonabsorbable
suture material or wire; also use fine interrupted sutures.
■ Fashion two flaps from the proximal tendon and gastrocnemius aponeurosis, each approximately 1 cm wide and 7 to 8 cm long. Leave these flaps attached at a point 3 cm proximal to the site of rupture.
■ Twist each flap 180 degrees on itself so that its smooth external surface lies next to the subcutaneous tissue as it is turned distally over the rupture.
■ Suture each flap to the distal stump of the tendon and to one another so that they cover the site of rupture completely.
■ Close the wound, being careful to approximate the tendon sheath over the site of repair.

OPEN REPAIR OF ACHILLES TENDON RUPTURE — LYNN

Lynn described a method of repairing ruptures of the Achilles tendon in which the plantaris tendon is fannedout to make a membrane 2.5 cm or more wide for reinforcing the repair. The method is useful for injuries less than about 10 days old. Later the plantaris tendon becomes incorporated in the scar tissue and cannot be identified easily.
■ Make an incision 12.5 to 17.5 cm long parallel to the medial border of the Achilles tendon.
■ Open the tendon sheath in the midline, and, with the foot held in 20 degrees of plantar flexion and without excising the irregular edges, sew the ends of the Achilles tendon together with 2-0 absorbable sutures.

If the plantaris tendon is intact divide its insertion on the calcaneus then, using forceps and beginning
distally, fan out the tendon to form a membrane.

■ Place this membrane over the repair of the Achilles tendon and suture it in place with interrupted sutures. When possible, cover the Achilles tendon for 2.5 cm both proximal and distal to the repair.
■ If the plantaris tendon also is ruptured, dissect it free from the Achilles tendon for several centimeters and divide it proximally using a tendon stripper.
■ Then pull the tendon distally into the incision, fan it out as a free graft, and cover the repair as already described.
■ Close the sheath of the Achilles tendon as far distally as possible without tension and close the wound.

OPEN REPAIR OF ACHILLES TENDON RUPTURE — TEUFFER

■ Expose the Achilles tendon and the tuberosity of the calcaneus through a posterolateral longitudinal
incision.
■ Identify and retract the sural nerve in the proximal part of the wound.
■ Detach the peroneus brevis tendon from its insertion through a small incision at the base of the fifth
metatarsal.
■ Excise the aponeurotic septum, separating the lateral and posterior compartments, and deliver the freed peroneus brevis into the first incision.
■ Dissect the tuberosity of the calcaneus and drill a hole large enough for passage of the tendon through the transverse diameter of the bone.

■ Pass the peroneus brevis tendon through this hole and back proximally beside the Achilles tendon reinforcing
the site of rupture and suture it to the peroneus brevis itself, producing a dynamic loop.

■ Turco and Spinella described a modification in which the peroneus brevis is passed through a midcoronal slit in the distal stump of the Achilles tendon. The graft is sutured medially and laterally to the stump and proximally to the tendon with multiple interrupted sutures to prevent splitting of the distal tendon stump. This modification can be beneficial if a long distal stump is present.

POSTOPERATIVE CARE
The cast is removed at 2 weeks, the wound inspected, and the staples or sutures removed unless subcuticular sutures were used for wound closure. Occasionally an additional week is required for proper wound healing before sutures are removed. A short-leg cast with the foot in gravity equinus is worn for an additional 2 weeks. At 4 weeks the cast is changed again and the foot is gradually brought to the plantigrade position over the following 2 weeks. Walking is gradually resumed with partial weight bearing on crutches during a 2-week period. At 6 to 8 weeks, a short-leg walking cast is applied with the foot in the plantigrade position and full weight bearing is allowed. Alternatively, a removable brace allowing only plantar flexion can be used as early as 4 to 6 weeks after surgery. Gentle active range-of-motion exercises for 20 minutes twice a day are begun. Isometric ankle exercises along with a knee-strengthening and hip-strengthening program can be instituted. Toe raises, progressive resistance exercises, and proprioceptive exercises, in combination with a general strengthening program constitute the third stage of rehabilitation. In reliable, well-supervised patients with good tissue repair this program can be accelerated with earlier use of dorsiflexion-stop orthoses and active range-of-motion exercises. Return to full unrestricted activity usually requires at least 6 months and often more.