Limited Open Achilles Repair Without Instrument-Guided Assistance

Abstract

Background:

The limited open Achilles tendon repair technique has recently gained popularity as a treatment option for acute Achilles tendon ruptures. This surgical technique video describes a limited open Achilles tendon repair without instrument guided assistance, demonstrating improved clinical outcomes for patients while also reducing reliance on operative equipment, cost, and the duration of surgery.

Indications:

The indications for this limited open Achilles tendon repair technique include an Achilles tendon rupture less than 6 weeks from injury occurring in the watershed area.

Technique Description:

The patient is prone and a 2- to 3-centimeter longitudinal incision is made over the Achilles tear. In the proximal stump, 3 nonabsorbable sutures are passed horizontally from proximal to distal direction. In the distal stump, the same is done in a nonlocking manner. The stumps are then reflected and the deep fascial compartment is released. The foot is plantarflexed to reduce tension on the repair site. The nonlocking sutures are tied sequentially from distal-distal to proximal-proximal direction. A running box suture using a nonabsorbable suture followed by 0-Vicryl around the rupture site is performed.

Results:

This technique has demonstrated, at a median follow-up of 3.7 years, restored pre-injury function along with no wound complications, re-ruptures, or re-operations in 33 patients. The median time from injury to surgery was 10 (range, 1-45) days and the mean time for returning to pre-injury level of activity was 5.6 (range, 1.7-22.1) months. After the procedure, patients demonstrated significant improvements in mean Foot and Ankle Disability Index (49.1-98.4), mean Visual Analog Scale pain score (4.8-0.2), and mean Foot and Ankle Outcome Score (FAOS) subscales such as FAOS pain (54.8-99.2), FAOS symptoms (84.6-97.0), FAOS activities of daily living (61.4-97.2), FAOS sports and recreational activity (39.5-98.5), and FAOS quality of life (39.7-88.7).

Conclusion:

Patients who underwent a limited open Achilles tendon repair without instrument-guided assistance demonstrated significant improvements in outcome scores with minimal complications.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Achilles tendon injuries comprise about 20% of all large tendon injuries, and over 75% of these occur during recreational sports. The ruptures have a strong association in men. There is a bimodal age distribution from 25 to 40 years, and >60 years of age. There does seem to be a prodromal period, especially in the younger age group.

This patient was a 24-year-old man who sustained an injury while playing basketball. He had a positive Homan’s sign test, decreased plantarflexion strength, and a palpable gap of 3 to 5 centimeters proximal to the insertion of the Achilles. X-rays show shadows of the edges of the rupture and opacities in Kager triangle, representative of blood that has collected there.

In general, operative indications are active individuals, patients with Achilles tendon ruptures <6 weeks, and ruptures that are in the watershed area anywhere between 3 to 5 centimeters proximal to the insertion site.

Nonoperative indications include patients that present delayed, have infections or wound healing issues at the rupture site, have comorbidities such as diabetes and obesity, and currently smoke. Compromised soft tissue surrounding the Achilles tendon and a history of deep vein thromboses in the operative leg are nonoperative indications as well.

Preoperatively, we will plan for a posterior midline approach, and this will be slightly centered over the rupture site itself, with two-thirds of the incision over the proximal stump and one-third of the incision in the gap of the rupture site. The patient’s position is prone on the operative table with a thigh tourniquet placed on the operative extremity, although you can do this with an Esmarch bandage.

The incision mark goes through all points of the epitendonous area. We will open up the epitenon, get into the rupture site, and get the hematoma out. We will find both stumps. In the proximal stump, I will take 1 or 2 Kocher forceps and grab the end of the tendon. As seen on the image to the right, we will pass 3 sutures.

The most proximal one to the rupture will have no marking; the second proximal suture will have 1 marking; and the third suture proximal to the rupture site has 2 markings. We will do the same thing distally where the more proximal suture has no markings, the second suture has 1 marking, and the distal suture has 2 markings.

Once these sutures are in the stumps, we will reflect both ends of the Achilles rupture, and we will find and identify the posterior compartment. We will release the posterior compartment sharply or with scissors.

In this repair, we do use nonabsorbable sutures, usually #2 sutures. There’s a variety of different brands you can use to create this repair. We want to make sure that we get the posterior compartment released fully so that the flexor hallucis longus muscle belly can rest up against the repair site. We tie the unmarked sutures together first, then the single marked sutures together second, and then the double marked sutures together last. You want to do anywhere from 5 to 7 knots, since any more than that will make the knots more prominent.

In addition, you can have one of these knots be more proximal while the other one is more distal, so that all the knots are not tied around the rupture site. Typically, I will try to tie the sutures around the rupture site, because when we do the 0-Vicryl (Ethicon, Inc.; Cincinnati, OH) repair, we will incorporate those knots into the actual repair site, and so they are not very prominent.

After tying the last set of sutures, we get 6 sets of sutures, or 3 strands, and 6 knots across the repair site, which is our ideal number of sutures passing the rupture site. At this point, I typically do a box type of suture repair by starting on either the proximal medial or proximal lateral end, but the direction does not matter.

We will run the suture in a nonlocking fashion down the medial portion of the repair all the way past the rupture site into the most distal aspect of the stump. I will then cross over to the lateral side and run this running suture up the lateral side all the way to the proximal lateral side, throwing it to the proximal medial side and then tying it all together.

Although this adds the 8 strands to cross the rupture site, I find that it is like adding belts and suspenders. It is just an additional set of very strong sutures that crosses the site and gives extra comfort that you have another differently oriented suture passing across the rupture site. Here I am tying this down, and again there can be anywhere from 3 to 5 knots in order to make sure it is not prominent.

We will take a 0-Vicryl suture and medially or laterally run this in a nonlocking fashion on the dorsal side and then on the under surface of the Achilles repair.

This has been shown to add more strength to our repair site, and it will also round out or tubularize the repair site a little bit more, making it cleaner and a little less bulky. I also will try to incorporate the series of 6 knots that I have previously created so that they are buried in the rupture repair that has been performed.

Next, we will take 2-0 Vicryl sutures, irrigate the repaired rupture site, and close the epitenon and subcutaneous tissues. I then use a liposomal bupivacaine product for postoperative pain control. I find that it helps quite a bit for these patients. The product is injected into the subcutaneous tissue, the subcutaneous tissue is closed, and then the skin is closed. The skin can be closed with staples or nylon sutures, depending on the surgeon’s choice.

In general, I like to perform this procedure within 4 to 6weeks, and make the incision directly posterior with two-thirds over the proximal stump and one-third over the distal stump. The total length of incision is only 2 to 3 centimeters. I will maximally plantarflex these patients so that the ends of the stumps are together. I do not try to overdo it and I do not try to have the resting plantarflexion less than that of the opposing side. You do want to avoid over retraction of the skin edges, because you do not want to have any skin edge necrosis.

Postoperatively, patients are non-weight-bearing in a Bulky Jones splint for the first 2 weeks. At week 2, the stitches come out and patients wear a pneumatic walking boot with a wedge that has multiple layers. Patients are allowed to have active dorsiflexion but no plantarflexion. Patients are allowed to weight bear with the wedged boot. Patients are on aspirin 325 milligrams twice daily for a month after their surgical repair. The heel lifts are removed in layers 1 week at a time.

Patients are weaned from the walking boot and are back to shoe wear by week 8. Proprioceptive exercises, open-chain exercises, as well as progression to standing bilateral heel raises takes place between weeks 6 to 10. After 12 weeks, the focus is on sports-specific training, the ability to perform single-leg hops, and return-to-sport.

Most patients on average state that their return to previous level of activity is 5.6 months, but real return-to-sport, especially with professional athletes, is 9 to 11 months.

Outcomes: patients who have completed 3 months of physical therapy really have no complications. This specific patient was able to resume normal activities as tolerated at 8 months postoperatively.

Our case series was published in 2020 and showed no postoperative complications when patients underwent the mini-open technique without instrument-guided assistance. Patients showed improvement in all of their patient-reported outcomes. Two other published papers showed results using smaller, mini-open incisions with no re-ruptures and low complication rates or no complication rates at all.

Thank you.