How to perform an achilles tendon repair
Source
Surgeon:
Lasse Rämö (orthopedic surgeon)
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Summary
Focus: Suturing a torn Achilles tendon and restoring the anatomical length of the tendon.
Key elements: Patient positioning, medial incision planning, peritenon handling, tendon suturing, wound closure, immobilization, aftercare, pitfalls, and complications.
Indications and Clinical Context
General
Medical experts: Lasse Rämö (orthopedic surgeon), Anna Ikonen (orthopedic surgeon)
Name of Procedure: Achilles tendon repair
Goal of Operation
Suturing a torn Achilles tendon and restoring the anatomical length of the tendon.
Problem
Achilles tendon rupture
Diagnosis
Injury of Achilles tendon (ICD-10: S86.0)
Short Pathophysiological Description
Achilles tendon rupture is one of the most common tendon injuries. It is typically seen in middle-aged individuals playing recreational sports. The tendon often ruptures in a sudden jump or push off. The patient may describe feeling a kick to his heel or calf and sometimes even hearing a tearing sound. Physiological degeneration of the tendon with aging makes the tendon more susceptible to injury. The rupture is typically located approximately 5 cm from the distal tendon insertion point.
Key Anatomical Structures
Achilles tendon
Sural nerve
Peritenon of the Achilles tendon
Plantaris tendon
Step-by-Step Technique
Patient Positioning, Anesthesia and Preparation
Patient is in prone position.
Spinal or general anesthesia can be used.
The patient’s feet should be placed over the distal end of the operating table and a small pillow may be placed under the affected limb. This helps in removing extra tension of the tendon. After the repair, the dorsiflexion of the ankles should look symmetrical.
Planning of the Skin Incision
Use a soft marker to sketch the edges of the Achilles tendon, the place of the rupture and the typical location of the sural nerve.
The skin incision is made close to the medial border of the tendon. The medial incision protects the sural nerve and the small saphenous vein on the lateral side. Furthermore, there is very little subcutaneous fat in the midline of the Achilles tendon and, thus, a medial incision also prevents irritation of the scar when wearing shoes.
Plan the skin incision so that it extends a few centimeters distally and proximally from the rupture site to allow enough room for the operative field.
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Skin Incision and Exposure of the Peritenon
There are no critical structures under the skin at the medial border of the Achilles tendon. The incision can be done by incising all the skin layers with one swift and careful move of the blade.
Advance through the subcutaneous fat to the surface of the peritenon. Cauterize the small bleeding vessels.
Place a retractor to ensure proper visibility.
Opening the Peritenon
Open the peritenon longitudinally. The peritenon may be intact and, if so, it should be opened to expose the torn Achilles tendon. However, sometimes the injury has already exposed the tendon.
Handle the peritenon with care. At the end of the procedure closure of the peritenon will help secure circulation and nutrition to the Achilles tendon.
The rupture of the Achilles tendon often creates a space or a separation between the peritenon and the tendon. It may not always be the case, so if necessary, you may use your finger to detach the tendon from the peritenon allowing easy placement of the sutures. It is advisable to not detach the peritenon extensively from the tendon to save the nutrition of the tendon tissue.
The plantaris tendon is often intact and right next to the Achilles tendon as seen below.
Suturing of the Tendon
Suture the tendon using size 2 non-absorbable sutures, for example.
There are several different suture techniques, e.g., Krackow, Kessler, and Bunnell sutures.
In this video we use Bunnell sutures. The needle is repeatedly advanced diagonally in slightly different layers of the distal end of the tendon. The suture should pass through the tendon at least 4 times about 3–4 cm distally from the rupture site to create a sufficient grip on the tendon.
Sutures are then placed similarly on the proximal side of the ruptured tendon.
Bring the ankle into plantar flexion and tie the ends of the sutures together. To prevent rotation of the tendon, both the medial and lateral sutures are tied separately, medial to medial and lateral to lateral.
The sutures may be checked by squeezing the calf which will then cause plantar flexion of the ankle (the Thompson test).In a rupture caused by chronic tendinitis, sometimes a proximal procedure, for example a V-Y plasty, may be necessary to achieve apposition. Sometimes a transposition of the flexor hallucis longus (FHL) tendon may be needed as an augmentation.
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Trimming the Rupture
Trim and suture ragged parts of the tendon using size 4-0 monofilament. The goal is to have a smooth surface with no loose parts of the tendon or visible defects.
Don’t forget to trim and suture the anterior part of the tendon.
Closing the Wound
The peritenon is closed using continuous size 2-0 absorbable suture.
The subcutaneous layer is closed using size 2-0 absorbable sutures, either single or continuous sutures.
The skin is closed using single or continuous sutures or with staples. These sutures can be removed after two weeks.
Protection of the Repair
Immobilize the ankle in equinus position using either a cast or a brace.
Educate the patient on partial weight bearing.
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Piftalls and Complications
Pitfalls
Incorrect Site of Incision
Incision to the lateral side of the tendon can cause a laceration of the sural nerve or the small saphenous vein. Incision directly in the midline of the tendon can cause irritation because there is very little subcutaneous fat in the midline and the scar can cause irritation when wearing shoes.
Generally, a medial incision is recommended to prevent these problems.
Careless Tissue Handling
Extensive separation of the skin and subcutis from the underlying tissues can produce problems with circulation and thus wound healing. Incise all layers of the skin with one swift but careful move of the blade.
Handle the peritenon with care so that it can be sutured at the end of the procedure and thus provide circulation and nutrition to the tendon.
The course of the sural nerve at the lateral side of the tendon should be considered when suturing the tendon and closing the wound.
Problems with the Tendon Sutures
The tendon repair can be too loose or too tight. Compare the posture of the injured ankle to the healthy side when tying the tendon sutures together. This ensures desirable tension for the repair: not too loose and not too tight.
Problems with Wound Closure
Avoid closing the skin too tight so that the incision wound heals adequately avoiding necrosis and infection.
Insufficient Immobilization
Non-restricted weight-bearing and unlimited range of motion predispose to failure of the repair. Gradual ROM and weight bearing exercises, preferably with a physical therapist, are recommended.
Complications
Injury to the Sural Nerve
The sural nerve is located on the lateral side of the Achilles tendon so it is advised to make the incision medially. There are also anatomical variants and the nerve can be divided into two branches at the level of the ankle. Injury to sural nerve can cause sensory problems at the lateral side of the foot varying from mild sensory deficits to severe neuropathic pain.
Wound Healing Problems, Infection
Careless soft tissue handling and patient selection predispose to wound healing problems and even difficult infections. Discuss different treatment options and their risks with your patient. Handle the skin as well as the peritenon with care.
Re-Rupture
Non-protected weight-bearing and non-restricted muscle exercises too early on in the healing process can lead to failure of the repair. Also, care should be taken to make tight knots with the tendon sutures to prevent loosening of the tendon repair.
Aftercare
Aftercare
General guidelines:
The skin sutures can be removed after two weeks.
Often there are local protocols for the aftertreatment of Achilles tendon repair. Generally, the ankle is held in equinus for a few weeks and partial weight-bearing is allowed with a brace. After 2–3 weeks the ankle is placed in 90 degrees dorsiflexion and range of motion (ROM) exercises without weight-bearing are implemented. Thromboprophylaxis is often recommended.
FAQ
FAQ
What is the goal of Achilles tendon repair?
The goal is suturing a torn Achilles tendon and restoring the anatomical length of the tendon.
Why is the skin incision made close to the medial border of the Achilles tendon?
The medial incision protects the sural nerve and the small saphenous vein on the lateral side, and it helps prevent irritation of the scar when wearing shoes because there is very little subcutaneous fat in the midline of the Achilles tendon.
What structures are listed as key anatomical structures?
The key anatomical structures are the Achilles tendon, sural nerve, peritenon of the Achilles tendon, and plantaris tendon.
How is the repair protected after wound closure?
The ankle is immobilized in equinus position using either a cast or a brace, and the patient is educated on partial weight bearing.
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