Current Concepts In Treating Achilles Tendon Ruptures
Approximately 20 years ago, I saw my first Achilles tendon rupture with bated breath. I thought the surgery was amazing and being able to tie a tendon back together that looked like strands of spaghetti was amazing. After the surgery, the patient wore an above-the-knee cast and the surgery was considered a full success.
However, I had a chance to follow the patient over the next year and found she had a miserable time with recovery. She had a terrible time with the long leg cast and was non-weightbearing for over two months. Accordingly, she had a great deal of muscle atrophy. After she was out of the cast, it took her six months to walk normally and over a year to get back to full activity. With all of that, she was still weaker on her surgical Achilles and never quite recovered.
Twenty years later, the treatment options have dramatically improved for Achilles tendon ruptures. After undergoing an anterior cruciate ligament (ACL) reconstruction on my knee, I noticed the difference among several doctors with the recovery process and surgical options. Some use one drill hole, some use two drill holes and some use three drill holes. Some use a brace and some do not. Overall, all the knee specialists suggested rapid physical therapy but only a few that I knew had thought out the importance of a rapid recovery process under controlled settings. By having a repair of the
ACL with rigid internal fixation, I was able to begin biking the day of surgery without a brace, making my recovery much faster.
This has changed my attitude towards Achilles rupture care and I would like to present what I believe is a relatively safe and effective Achilles repair and recovery process.
Prior to surgery, it is important to consider the type of tear, the severity of the tear and the length of time since the tear occurred. In cases of longstanding tear, a flexor hallucis longus tendon transfer to the calcaneus may be necessary and this will require a different recovery process.
With this in mind, let us consider an acute Achilles tear that one sees right away and can care for rapidly.
In such cases, the physician can use ultrasound or magnetic resonance imaging (MRI) to check the level of tear and the amount of proximal Achilles retraction. I prefer using diagnostic ultrasound as it allows a dynamic Achilles test. Dorsiflex and plantarflex the ankle, and check the amount of gapping about the Achilles tear region. Podiatrists can also check the proximity of the Achilles tendon ends under ultrasound guidance.
Key Considerations For Pre-Op Planning
After checking the Achilles, plan the surgery. I suggest a short period of rest and icing for two to three days to decrease edema. It is not often necessary to wait for swelling to decrease in Achilles tendon ruptures as the region does not seem to swell severely.
On the day of surgery, it is essential to plan for the worst case scenario. It is not uncommon to have a low energy Achilles tear, which has severely shredded ends that are difficult to put back together. In such cases, it is difficult to get a very strong repair with suture only. I prefer to augment the Achilles repair with a graft material such as GraftJacket (Wright Medical). The addition of an external graft material facilitates wrapping of the tendon in order to allow the shredded strands a better medium for healing. This approach also leads to less scar formation.
Step-By-Step Surgical Pearls
Plan the surgery with the smallest incision that will allow adequate repair. Centering a 5- to 6-cm incision over the region of tear is adequate in most acute tears. The surgeon should limit deep dissection and tag the peritenon for later repair.