A Closer Look At Mini-Incision Repair Of The Acute Achilles Tendon Rupture

There has been a variety of research looking at treatments for acute Achilles tendon ruptures including non-operative repair with different rehabilitation protocols, extensile open repairs, percutaneous repairs, percutaneous repair with ultrasound guidance, percutaneous repair with endoscopic guidance and mini-open repairs.1-3 Some physicians advocate for surgical repair whereas others insist that an operation is unnecessary and poses an unacceptable risk.4

   The mini-incision approach to acute Achilles tendon ruptures seems to eliminate the most common complications of the extensile open procedures as well as those of the percutaneous methods. The most common complication of the percutaneous approach is poor apposition of the tendon ends. The mini-incision allows for direct visualization of the tendon ends during knot tying. This minimizes the risk of poor apposition.

   The sural nerve is also injured more frequently with percutaneous techniques. This particular mini-incision technique places the lateral incisions just medial to the lateral tendon edge to avoid the sural nerve. The main complication of the extensile open procedure is wound dehiscence and its sequelae. One can minimize wound dehiscence with the mini-open approach. Since the soft tissue envelope and the peritenon are not stripped from the tendon, the blood supply from the peritenon and the perforating vessels to the soft tissue envelope remain intact, thus preventing wound dehiscence and skin breakdown.

Step-By-Step Insights On The Technique

After performing an appropriate physical exam and surgical workup, one can proceed to surgery. Ensure appropriate anesthesia and prone positioning of the patient. One can place a thigh tourniquet but this is not necessarily inflated. Prep the operative extremity and drape it in the typical sterile fashion.

   Draw the course of the sural nerve from the gastroc musculotendinous junction to the lateral foot. Make a 3 to 4 cm longitudinal incision over the tendinous defect from skin to the tendon. Making a small vertical stab incision allows for extension of the incision vertically as needed. The surgeon delivers both ends of the ruptured tendon into the wound. Place a clamp on the proximal end of the ruptured tendon in order to hold this under tension for suture placement.

   Place three stab incisions on either side of the tendon in 2 to 3 cm intervals proximal and distal to the ruptured ends. One would use a hemostat to bluntly dissect to the tendon. The surgeon then passes the suture (#5 braided non-absorbable) into the tendon at the rupture site through the tendon to the most distal stab incision angled across the tendon. Then pass the suture back into the same stab incision across the tendon and out the next distal stab incision in a crossing “shoe lacing” pattern. Repeat this to the most proximal stab incision. Then pass the suture horizontally through the tendon to its paired stab incision. Pass the suture in a zig-zag fashion back distally into the mini-incision. The two suture ends exit the proximal stump of the Achilles tendon.

   Using a separate suture, repeat this pattern on the distal stump. Tie the suture ends with the tendon ends visualized and approximated. Bury the suture ends anterior to the tendon. This provides a two-core suture repair.

   Using a key elevator between the tendon and the subcutaneous tissue, mobilize the tissue to release any adhesions. Reapproximate the incisions with sutures. Dress the extremity and place it in either a plantarflexed splint or removable cast boot with a 9/16-inch heel lift.

   The patient should remain non-weightbearing until the first post-op visit at 12 to 14 days. The patient may begin protected, 50 percent weightbearing in a removable cast boot with an appropriate heel lift and begin physical therapy at two weeks. Physical therapy can progress as the patient tolerates. Return to activity ranges between five to nine months.

In Conclusion

Minimal incision Achilles tendon repair is indicated for acute mid-substance ruptures. It is not indicated in ruptures at the musculotendinous junction, avulsions involving bone, re-ruptures or chronic ruptures. It also requires the distal portion of the tendon to be a minimum of 2 cm in length. The minimal incision approach allows for direct visualization of the apposition of the tendon ends upon knot tying as opposed to the purely percutaneous methods. This helps to minimize gapping and scar formation.

   Other benefits include a decrease of subcutaneous tendinous adhesions and increased preservation of the blood supply to the Achilles tendon.1 In theory, the preservation of the blood supply should decrease the risk of re-rupture and aid in a quicker recovery. Since a tourniquet is not necessary and rarely used for the mini-open repair, there may be a decrease in the risk of postoperative thromboembolic events.

   There are many studies comparing the different methods of Achilles tendon rupture treatments. While surgical techniques vary from the incision length to the length of the operation to tourniquet use to suture material and suture technique, it seems that the real variable is the postoperative treatment of when physical therapy starts and how aggressively it progresses.

   Dr. Bark is a fellow in limb lengthening and deformity correction at the Rubin Institute for Advanced Orthopedics in Baltimore.

   Dr. Jennings is affiliated with the Department of Orthopedics and Podiatry at the Palo Alto Medical Foundation in Mountain View, Calif. She is a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Rush is affiliated with the Department of Orthopedics at the Palo Alto Medical Foundation in Mountain View, Calif. He is a Fellow of the American College of Foot and Ankle Surgeons.

References

1. Soubeyrand M, Serra-Tosio G, Campagna R, Molina V, Sitbon P, Biau DJ. Intraoperative ultrasonography during percutaneous Achilles tendon repair. Foot Ankle Int. 2010;31(12):1069-74.
2. Chan KB, Lui TH, Chan LK. Endoscopic-assisted repair of acute Achilles tendon rupture with Krackow suture: an anatomic study. Foot Ankle Surg. 2009;15(4):183-6.
3. Mukundan C, El Husseiny M, Rayan F, Salim J, Budgen A. “Mini-open” repair of acute tendo Achilles ruptures--the solution? Foot Ankle Surg. 2010;16(3):122-5.
4. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. 1999;81(7):1019-36.