Edited by Vinod K. Panchbhavi, MD
An Achilles tendon repair is often performed as treatment for a ruptured Achilles tendon
Open Achilles Tendon repair
An Achilles tendon repair is most commonly performed through an open incision, located over the site of tendon rupture at the back of the leg. The incision is dissected down to the ruptured Achilles tendon. Once the ruptured Achilles is reached, the torn ends are trimmed and cleaned up to suture them for reattachment. The ankle is positioned with toes pointing down so that the repair can be performed and the area of the repair is not under tension. Once tendon ends have been secured the wound is carefully closed. (see Figure 1)
Another technique that is sometimes used to repair a ruptured Achilles is performed through a “mini-open” incision. In this procedure a small horizontal incision or sometimes a vertical incision is made over the Achilles. A commercially available device is then used to facilitate the reconnection of the ruptured tendon with sutures in a blinded manner. The advantages of the mini-open technique include less soft tissue damage and less scaring and better cosmesis. However, the disadvantages include a higher rate of local nerve injuries as unlike in the open procedure the sutures are introduced without exposing the full length of the tendon which can make it difficult to ensure that the nerve is out of the way of the repair. The nerve that can potentially be injured may cause numbness over the side of the foot near the little toe. It is possible that the repair itself may not be as strong as the more common technique potentially leading to a higher re-rupture rate. (see Figure 2)
Figure 1: Open repair of Achilles tendon rupture
Figure 2: Mini Incision Repair
Typical Standard Recovery
During the first 6-8 weeks, the foot is immobilized in a cast to allow the tendon and the surrounding tissues to heal properly. In addition, the tendon needs to be protected because the healing Achilles tendon may still be too weak to withstand the force of normal walking. After the 6-8 weeks, patients are placed in a removable boot, often with a small heel lift to take some of the load off of the Achilles. At this point, patients can begin walking, but at a slow pace initially. Physical therapy working on range of motion and low resistance strengthening is usually started at 6-8 weeks post surgery. Gradually over a series of weeks, the heel lift is removed, bringing the ankle back into its neutral position. In a traditional recovery the patient can transition into a regular shoe around 9-14 weeks post-surgery.
More Aggressive Achilles Rehabilitation
Younger, more athletic patients who are very displined might benefit from a more Aggressive Athletic Rehabilitation.
Potential General Complications
- Asymmetric Gait (leading to pain elsewhere)
- Deep Vein Thrombosis (Blood Clot)
- Pulmonary Embolism (PE)
- Scar Irritation
The incision can be made in two different locations: on the back or on the side of the Achilles. Although the incision can be made on the back of the Achilles, an incision on the side will tend to avoid irritation from the scar when rubbed against the shoe during normal walking.
Potential Specific Complications
- Wound healing
Although this is usually a general complication for most procedures, the wound healing complication is particularly concerning for an Achilles tendon repair. This is because the tendon itself has relatively little soft-tissue coverage and this area of skin has a notoriously poor blood supply. Therefore, any type of wound healing problem can easily end up involving the tendon itself. For most patients, there is approximately a 2-5% chance of a significant wound healing problem. However, the risk of a wound healing problem increases significantly in smokers and diabetics.
A deep infection following an Achilles tendon repair can be a devastating problem. Often, an infection will occur if there is an associated wound healing problem that allows bacteria from the outside world to contaminate the Achilles repair. Treatment may require not only antibiotics, but potentially the removal of all suture materials and, in some instances, removal of the tendon itself. Smokers and Diabetics are at an increased risk of a serious wound infection following Achilles Tendon repair surgery.
- Re-rupture of the Achilles Tendon:
The re-rupture rate is significantly lower in operatively (Achilles Tendon Repair) treated patients (2-5%) compared to patients treated non-operatively (8-15%). However, re-rupture is still a known complication.