Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

511. Limited Open Repair of Achilles Tendon Ruptures: Perspective 1

Mathieu Assal

DEFINITION

images Achilles tendon ruptures usually occur 3 to 4 cm above the calcaneal tuberosity.

images Although most injuries are “complete” ruptures, “partial” injuries have been described.

ANATOMY

images The Achilles tendon is about 9 cm long and 0.9 cm in diameter.

images The proximal part is composed of the gastrocnemius and soleus tendons.

images The distal portion inserts onto the posterior aspect of the tuberosity of the calcaneus.

images The Achilles tendon is surrounded by the paratenon, a delicate envelope that contributes to tendon vascularization.

images There is an area of poor vascularity located between 2.5 cm and 5 cm above the calcaneal tuberosity.

PATHOGENESIS

images Rupture of the Achilles tendon is a common injury among high-level athletes, recreational sports enthusiasts, or even sedentary individuals.

images Rupture of the Achilles tendon usually occurs during forceful dorsiflexion of the ankle.

images Patients often describe hearing or feeling a “pop” in the back of their ankle.

images Intratendinous degeneration can be found histologically.

images Association with cortisone and fluoroquinolone use has been demonstrated.

images This is typically a lesion of middle age, with peak incidence during the third and fourth decades.

NATURAL HISTORY

images There is a great deal of controversy concerning the treatment of an acute rupture of the Achilles tendon.

images Conservative treatment is found to have a higher rate of tendon rerupture and loss of strength because the tendon heals in an elongated position.

images The major factor motivating surgeons to use a nonoperative approach appears to be avoiding the wound complications that occur with an operative repair.

images An increasing number of reports in the literature have tended to favor operative treatment of an acute rupture of the Achilles tendon.

images The exact type of operative procedure and the postoperative regimen remain controversial.19 Mini-invasive techniques are associated with a lower complication rate.1013

images If soft tissue complications are avoided, excellent functional results and full return to previous activity can be expected.

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Reprinted with the permission from The Journal of Bone and Joint Surgery, Inc, License Number 1666441335096

PHYSICAL FINDINGS

images Physical examination reveals moderate swelling about the posterior aspect of the ankle.

images Patients are usually able to walk, although with moderate pain.

images With the patient prone, spontaneous excess dorsiflexion of the involved ankle is noted.

images In most cases a tender defect (“soft spot”) can be palpated in the Achilles tendon between 2.5 and 5 cm proximal to its insertion into the calcaneal tuberosity.

images The Thompson squeeze test is positive.

images Patients have difficulty walking on their toes or rising up on their heels.

IMAGING AND DIAGNOSTIC STUDIES

images History and physical examination are sufficient to confirm the diagnosis.

images Since these injuries occur in a traumatic setting, plain radiographs of the ankle are strongly advised.

images There have been many reports of associated ankle fractures (medial malleolus).14

images Calcaneal (tuberosity) avulsion will appear on the lateral view.

images Ultrasound and MRI are not required for the diagnosis of Achilles tendon rupture but may be of value when the diagnosis is questionable.

DIFFERENTIAL DIAGNOSIS

images Ankle sprain

images Ankle fracture

images Tennis leg (gastrocnemius tear)

images Acute paratenonitis

images Calcaneal (tuberosity) avulsion

images Plantaris tendon rupture

NONOPERATIVE MANAGEMENT

images Nonoperative treatment of acute Achilles tendon ruptures involves prolonged immobilization.

images Prolonged immobilization is associated with musculoskeletal changes (atrophy), increased time necessary for rehabilitation, and delayed return to work and preinjury activities.

images In randomized studies the rerupture rate has been found to be much higher in the nonoperative group.

images However, nonoperative treatment avoids surgical complications.

images Nonoperative treatment should be considered in elderly patients with limited functional expectations, patients with significant tobacco or alcohol addictions, patients receiving chronic cortisone treatment, patients with vascular disease, and patients with severe comorbidities such as renal failure.

Indications and Contraindications

images The indication for this technique is an acute (less than 3 weeks) Achilles tendon rupture occurring between 2.0 and 7.0 cm above the tuberosity of the calcaneus.

images Greater than 90 percent of ruptures of the Achilles tendon occur in the area between 2 and 8 cm above the calcaneal tuberosity.15

images We believe that ruptures occurring more than 8 cm above the tuberosity (muscular ruptures) can be treated nonoperatively, while ruptures occurring less than 2 cm from the tuberosity necessitate fixation directly to bone.

images Contraindications include chronic rupture greater than 3 weeks in duration, previous local surgery, steroid use, open ruptures and lacerations greater than 6 hours in duration, complex open ruptures with soft tissue defects, and ruptures not occurring between 2 and 8 cm above the tuberosity of the calcaneus.

SURGICAL MANAGEMENT

Preoperative Planning

images Plain films should be reviewed for fracture, avulsion, and calcific tendinopathy.

images All imaging studies are reviewed.

images An examination under anesthesia should be performed before positioning the patient to reconfirm the side of injury.

Positioning

images The patient is placed prone on the operating table.

images A tourniquet is applied around the upper thigh.

images Both legs are included in preparation and draping to compare Achilles tendon tension and spontaneous plantarflexion intraoperatively.

images Plastic draping is not used (the technique involves percutaneous steps).

images Patients receive antibiotic prophylaxis.

images

FIG 1  The Achillon® instrument, with a straight needle and suture passed through one of the levels of holes.

Instrumentation

images The Achillon (Newdeal, Integra Life Science) was designed by this author and is made of either a rigid polymer or stainless steel (FIG 1).

images It is designed to guide the passage of the sutures.

images It is composed of a pair of internal branches connected to a pair of external branches, with each branch having a line of apertures at the same level to allow easy and accurate passage of the sutures through all four branches.

images The two internal branches are at an 8-degree angle to each other, following the V-shaped anatomic form of the tendon.

images A micrometric screw allows for varying the opening of the branches according to tendon morphology.

images A straight needle with its attached suture is used with a needle driver, designed to provide a larger support surface to push the needle through the soft tissues and at the same time protect the surgeon by preventing perforation of the glove from the end of the needle.

TECHNIQUES

images Palpate the site of injury, represented by the gap or soft spot (TECH FIG 1A).

images The incision is paratendinous and medial (TECH FIG 1B), beginning at the soft spot and extending about 2.0 cm proximally.

images Gently retract the skin and subcutaneous tissue with hooks and identify the paratenon (TECH FIG 2A).

images Carefully open the sheath and tag each edge with a stay suture (TECH FIG 2B).

images Identify both stumps of the ruptured tendon (TECH FIG 3A) and carefully note the exact site of rupture.

images Introduce the Achillon in the closed position under the paratenon in a proximal direction, holding the tendon stump with a small clamp under the instrument (TECH FIG 3B).

images The tendon stump is located between the two internal branches (TECH FIG 3C).

images As the instrument is introduced, progressively widen it, holding the tendon stump firmly with the clamp.

images Confirm the position of the guide by external palpation; you should feel the tendon between the central (internal) branches of the instrument.

images Pass three sutures from lateral to medial, usually beginning with the most proximal hole of the instrument (TECH FIG 4A,B).

images Hold the end of each suture with a small clamp to keep them separate from each other.

images Slowly withdraw the instrument while progressively closing the branches (TECH FIG 5A).

images This maneuver results in the sutures sliding from an extracutaneous position to a peritendinous position, and thus the tendon itself is the only tissue held by the sutures (TECH FIG 5B).

images Apply traction to the three suture pairs to ensure they are firmly anchored in the tendon, and individually clamp them to prevent any confusion.

images Perform the same sequence on the distal stump: introduce the instrument under the tendon sheath and push it until it touches the calcaneus (TECH FIG 6A).

images

TECH FIG 1  Illustration showing the skin incision, begun at the gap or soft spot (A), paratendinous and medial, and extended one and onehalf to two centimeters proximally (B).

images

TECH FIG 2  Illustration showing the sheath opened longitudinally in the midline (A) and a stay suture in place (B).

images

TECH FIG 3  Illustration showing the forceps grasping the proximal tendon stump (A), and introduction of the instrument proximally under the paratenon (B,C).

images

TECH FIG 4  Illustration showing introduction of the first needle (A), and illustration showing all three sutures in the proximal tendon (B).

images

TECH FIG 5  Illustration showing the instrument being withdrawn (A) bringing the sutures from an extra-cutaneous to a peritendinous position (B).

images

images

TECH FIG 6  Illustration showing the exact same sequence performed on the distal stump. (A) Introduce the instrument under the tendon sheath and push it until it touches the calcaneus. (B) Illustration showing the sutures organized for tightening. (C) Illustration showing the tendon reduction performed under direct vision, confirming apposition of the tendon ends. (D) Illustration showing closure of the skin with intradermal sutures.

images All the sutures are now organized for tightening (TECH FIG 6B), which is carried out with corresponding pairs, and the tendon reduction is under direct visual control (TECH FIG 6C).

images If it is difficult to ascertain tendon length and reduction because the ends are too frayed, compare the tendon tension to the opposite leg.

images Close the tendon sheath, and then the skin with intradermal sutures (TECH FIG 6D).

images No drain is used.

images Apply a splint holding the ankle in 30 degrees of flexion before moving or waking up the patient.

images

POSTOPERATIVE CARE

images Low-molecular-weight heparin (subcutaneous administration) is used to prevent deep vein thrombosis for 3 weeks postoperatively.

images Our early functional rehabilitation program, carefully supervised by the physical therapist, is divided into four stages.

images For the first 2 weeks patients are allowed partial weight bearing (30 to 45 pounds) and maintained in the splint full time.

images Then gentle ankle range of motion (flexion and extension) is begun, as well as thigh muscle exercises and the use of a stationary bicycle.

images The goal is to reach a neutral ankle position by the end of the third week.

images After 3 weeks, full weight bearing is allowed with continuous use of the protective splint.

images At the end of 8 weeks the splint is discontinued and weight bearing is allowed without any external support.

images A more intensive program of ankle range of motion, stretching, and isometric and proprioceptive exercises is instituted.

images Jogging is allowed at 3 months, and more demanding sports at 5 months.

OUTCOMES

images This limited open procedure with use of the Achillon instrument provides the advantage of an open repair but avoids the soft tissue problems associated with open repair.

images We published a prospective multicenter study in 2002 including 82 patients.12 Results showed no wound healing problems and no infections. No patient noted a sensory disturbance in the sural nerve distribution. All patients returned to their previous professional or sporting activities. The mean AOFAS score was 96 points (range 85 to 100 points).

images Complications occurred in three patients. Two of them were noncompliant and removed the orthosis within the first 3 weeks postoperatively, thus disrupting the repair by a new injury. One patient fell 12 weeks after the surgery and sustained a rerupture. All three new injuries were repaired with an open surgical procedure.

images

images Isokinetic results: The concentric peak torque was performed with the ankle in plantarflexion at 30°/s and 60°/s of angular velocity, after correction for dominance. There was no significant difference between the injured and uninvolved sides (Table 1). Endurance testing at 120°/s also revealed no difference between sides.

images Three recent reports describe similar excellent results using the exact surgical technique and Achillon instrument, thus providing further confirmation of its important role in the repair of acute Achilles tendon ruptures.

COMPLICATIONS

images Disruption of the repair related to the patient's noncompliance with the rehabilitation protocol (before the third month postoperatively)

images Rerupture of the healed Achilles tendon (after the third month postoperatively)

images Sural nerve injury

images Infection

images Deep venous thrombosis

REFERENCES

1.     Cetti R, Christensen SE, Ejsted R, et al. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 1993;21: 791–799.

2.     Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med 1998;25:79–100.

3.     Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019–1036.

4.     Soldatis JJ, Goodfellow DB, Wilber JH. End-to-end operative repair of Achilles tendon rupture. Am J Sports Med 1997;25:90–95.

5.     Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study. Am J Sports Med 1990;18:188–195.

6.     Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med 1995;23:392–395.

7.     Haji A, Sahai A, Symes A, et al. Percutaneous versus open tendo Achillis repair. Foot Ankle Int 2004;25:215–218.

8.     Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med 2005;33:1369–1379.

9.     Calder JD, Saxby TS. Independent evaluation of a recently described Achilles tendon repair technique. Foot Ankle Int 2006;27:93–96.

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

11. Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. J Bone Joint Surg Br 1995;77:60–63.

12. Assal M, Jung M, Stern R, et al. Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 2002;84-A: 161–170.

13. Rippstein P, Easley M. “Mini-open” repair for acute Achilles tendon ruptures. Tech Foot Ankle Surg 2006;5:3–8.

14. Assal M, Stern R, Peter R. Fracture of the ankle associated with rupture of the Achilles tendon. Case report and review of the literature. J Ortho Trauma 2002;16:358–61.

15. DiStefano VJ, Nixon JE. Achilles tendon rupture: pathogenesis, diagnosis, and treatment by a modified pullout wire technique. J Trauma 1972;12:671–677.



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