Achilles tendon rupture: Minimally invasive repair
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The incidence of achilles ruptures is increasing, probably due to the increase in sports and exercise amongst an older population.
Whether its treated surgically or conservatively, the recovery is prolonged and it will take 8-10 months to return to full activity and sports and over a year to reach maximum recovery. The goal of treatment is to achieve maximum function in the calf muscles and this requires intensive input from physiotherapy and from the patient to achieve this.
We know from the original papers by Mason & Allen in 1948, that tendons heal quickest and strongest if they are immobilised for a short period and then mobilised within a protected environment. This is the focus of current achilles rupture management. We also know that early weightbearing is not detrimental if the ankle is protected in plantarflexion.
It is important to know the severity of the injury and ultrasound is the investigation of choice – it will confirm the site of rupture and also the presence of any gap in the tendon ends. Ruptures at the proximal muscul0tendinous junction do not require surgery and should be treated conservatively (surgery may still be indicated in professional athletes). Ruptures or avulsions at the distal end usually require surgery as there is often a large gap. This will require open surgery (see achilles avulsion).
Most ruptures occur in the midportion 6-7cm above the insertion and the ultrasound will confirm most importantly if the tendon ends appose in plantarflexion. Recent studies have shown that little or no benefit with surgery in patients where there is a gap <5mm and these can be successfully treated in a well structured rehabilitation programme with protection in an equinus cast or boot, with reducing equinus over several weeks. If there is a significant gap >5mm then, in my opinion, surgery is required although some surgeons use >10mm gap as the cut off.
In professional athletes or where maximal achilles function is essential for work, I recommend surgical repair – long term function studies have confirmed significant benefits in plantarflexion torque with surgery.
Ideally, the surgery should be performed using minimally invasive techniques – these have been shown to have significantly lower risks of wound and infective complications, when compared to open surgery. The technique described here is one method – there are others that use jigs to guide the suture placement (Achillon and PARS devices)
Readers will also find the following OrthOracle techniques of interest:
Grassi et al. Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery. J Bone Joint Surg Am. 2018
Author:Pete Rosenfeld FRCS (Tr & Orth)
Institution: St Marys Hospital and The Fortius Clinic, London, UK.