Orthopedics

Interview 

Achilles Tendon Rupture and Subsequent Repair

Keith L. Wapner, MD

Abstract

Dr Wapner is from the University of Pennsylvania, Philadelphia, Pennsylvania.

Dr Wapner has no relevant financial relationships to disclose.

Correspondence should be addressed to: Keith L. Wapner, MD, 230 W Washington Sq, 5th Floor, Philadelphia, PA 19106.

Achilles tendon injuries are deceleration injuries. They occur when the gastrocsoleus muscle forcibly retracts, such as when you land after going up for a rebound in basketball, causing a sudden unexpected dorsiflexion to the ankle. They can occur while pushing off with the knee extended, as in tennis while lunging for a shot. They can also occur with sudden violent dorsiflexion force on a plantar flexed foot. These traumatic ruptures occur because the force exerted on the suddenly rapidly loaded tendon exceeds the tendon’s tensile strength.

I generally do an open repair of the Achilles tendon using a nonabsorbable suture. I use a medial approach just anterior to the Achilles tendon to avoid a posterior scar and to avoid the sural nerve laterally. Dissection is always done deep to the paratenon to avoid injury to the blood supply to the skin. The goal is to debride any devitalized tissue and then anastamose the ends of the tendon back to restore the normal resting length of the muscle, to avoid overlengthening and subsequent weakness. I use a modified Bunnell-type stitch but generally place 2 to 3 passes depending on the degree of mop-handle tearing. Postoperatively, I begin active range of motion and protected weight bearing at 4 weeks and strengthening at 8 weeks.

I do not have a cut-off for primary repair of the tendon, but if the rupture is older than 3 months, if the tendon ends are devitalized, or if I have any difficulty getting the ends of the tendon opposed, I will add a flexor hallucis longus tendon transfer to reinforce the repair and give better strength to the tendon.

I will initially try nonoperative treatment. If the tendinosis is severe, I first immobilize the patient in a molded ankle-foot orthosis until the tenderness is diminished. I start range of motion exercises, then advance to theraband strengthening and eccentric exercises. I wean the patient out of the orthosis and continue with these exercises. If the tendinosis is not severe, I start with the therapy first. If this is not successful in resolving the patient’s pain, or if the patient does not wish to try nonoperative treatment, I give them the option of surgery with debridement of the tendon and flexor hallucis longus transfer. I will harvest the flexor hallucis longus from a separate midfoot incision and pass it through a hole in the posterior calcaneus, then weave the flexor hallucis longus up through the Achilles.

In the acute setting, patients who are not operative candidates because of concomitant medical problems benefit from nonoperative treatment. Some studies show that closed treatment will give satisfactory results, but most of these rely on serial ultrasound studies to assure that the tendon ends are opposed to prevent healing with an overlengthened tendon.

In the setting of chronic tendinosis, patients who do not wish to significantly limit their activity or undergo surgery can be managed with molded ankle-foot orthosis bracing.

The classic test for an Achilles rupture is the Thompson test. The examiner lays the patient prone with the foot extending past the end of the examination table, then squeezes the calf muscle. If the patient’s foot does not plantar flex, this indicates that the tendon is ruptured. This can also be done prone with the patient’s knee flexed. At times, a palpable gap may be present in the tendon, but this is less reliable. Plantar…

Dr Wapner is from the University of Pennsylvania, Philadelphia, Pennsylvania.

Dr Wapner has no relevant financial relationships to disclose.

Correspondence should be addressed to: Keith L. Wapner, MD, 230 W Washington Sq, 5th Floor, Philadelphia, PA 19106.

What are the leading causes of Achilles tendon rupture?

Achilles tendon injuries are deceleration injuries. They occur when the gastrocsoleus muscle forcibly retracts, such as when you land after going up for a rebound in basketball, causing a sudden unexpected dorsiflexion to the ankle. They can occur while pushing off with the knee extended, as in tennis while lunging for a shot. They can also occur with sudden violent dorsiflexion force on a plantar flexed foot. These traumatic ruptures occur because the force exerted on the suddenly rapidly loaded tendon exceeds the tendon’s tensile strength.

What is your technique for an Achilles tendon repair?

I generally do an open repair of the Achilles tendon using a nonabsorbable suture. I use a medial approach just anterior to the Achilles tendon to avoid a posterior scar and to avoid the sural nerve laterally. Dissection is always done deep to the paratenon to avoid injury to the blood supply to the skin. The goal is to debride any devitalized tissue and then anastamose the ends of the tendon back to restore the normal resting length of the muscle, to avoid overlengthening and subsequent weakness. I use a modified Bunnell-type stitch but generally place 2 to 3 passes depending on the degree of mop-handle tearing. Postoperatively, I begin active range of motion and protected weight bearing at 4 weeks and strengthening at 8 weeks.

What is your cut-off for a primary repair, and how do you treat one if it is past your cut-off?

I do not have a cut-off for primary repair of the tendon, but if the rupture is older than 3 months, if the tendon ends are devitalized, or if I have any difficulty getting the ends of the tendon opposed, I will add a flexor hallucis longus tendon transfer to reinforce the repair and give better strength to the tendon.

How do you treat chronic Achilles tendinosis? When do you operate?

I will initially try nonoperative treatment. If the tendinosis is severe, I first immobilize the patient in a molded ankle-foot orthosis until the tenderness is diminished. I start range of motion exercises, then advance to theraband strengthening and eccentric exercises. I wean the patient out of the orthosis and continue with these exercises. If the tendinosis is not severe, I start with the therapy first. If this is not successful in resolving the patient’s pain, or if the patient does not wish to try nonoperative treatment, I give them the option of surgery with debridement of the tendon and flexor hallucis longus transfer. I will harvest the flexor hallucis longus from a separate midfoot incision and pass it through a hole in the posterior calcaneus, then weave the flexor hallucis longus up through the Achilles.

Which patients benefit from nonoperative treatment of an Achilles tendon rupture?

In the acute setting, patients who are not operative candidates because of concomitant medical problems benefit from nonoperative treatment. Some studies show that closed treatment will give satisfactory results, but most of these rely on serial ultrasound studies to assure that the tendon ends are opposed to prevent healing with an overlengthened tendon.

In the setting of chronic tendinosis, patients who do not wish to significantly limit their activity or undergo surgery can be managed with molded ankle-foot orthosis bracing.

What should the physical examination entail for an acute Achilles tendon rupture?

The classic test for an Achilles rupture is the Thompson test. The examiner lays the patient prone with the foot extending past the end of the examination table, then squeezes the calf muscle. If the patient’s foot does not plantar flex, this indicates that the tendon is ruptured. This can also be done prone with the patient’s knee flexed. At times, a palpable gap may be present in the tendon, but this is less reliable. Plantar flexion against resistance is also unreliable, as the patient may be able to generate significant plantar flexion force with the flexor hallucis longus and flexor digitorum longus muscles.

What is the role of imaging in diagnosing acute Achilles tendon ruptures?

Generally, imaging other than radiographs to rule out concomitant fractures is not required. If the diagnosis is not clear on physical examination, it can be confirmed by sonogram or magnetic resonance imaging.

Does immediate mobilization following Achilles tendon rupture surgery lead to a quicker recovery?

Immediate mobilization should be delayed until there is either surgical repair of the tendon or sonogram evidence of healing of the tendon ends if nonoperative treatment is used. Early mobilization has been shown to improve functional long-term results and is widely accepted.

What does the future hold for the treatment of Achilles tendon rupture?

The use of biologics may lead to earlier and enhanced healing of the Achilles tendon. This is an area where further research and ongoing studies may provide us with better treatment options.

In this issue of ORTHOPEDICS, Dr Keith L. Wapner discusses his technique for Achilles tendon repair and which patients may benefit from nonoperative treatment.

Authors

Dr Wapner is from the University of Pennsylvania, Philadelphia, Pennsylvania.

Dr Wapner has no relevant financial relationships to disclose.

Correspondence should be addressed to: Keith L. Wapner, MD, 230 W Washington Sq, 5th Floor, Philadelphia, PA 19106.

10.3928/01477447-20110526-18

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