Complete Ruptures of the Achilles Tendon

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Medscape Orthopedics. 2001;5(3) 

In This Article

Treatment of Acute Achilles Tendon Ruptures

Nonsurgical Treatment

The choice of treatment for acute ruptures of the Achilles tendon continues to be controversial. Nonsurgical treatment was favored prior to the turn of the century and regained favor during the 1970s. The conservative camp argues that equally good results can be obtained with cast immobilization without the complications associated with surgery. In 1972, Lea and Smith[12] reported on 66 patients who underwent 8 weeks of below-the-knee cast immobilization with the foot in gravity equinus. The patients gradually increased their weight bearing and used a 2.5-cm heel lift for 4 weeks after cast removal. Although 11% re-ruptured their tendon, 52 out of 55 patients stated they were satisfied with their result. One year later, The Lancet published an editorial stating, "... in view of the excellent results obtainable by conservative treatment it is doubtful whether surgical repair in closed rupture of the Achilles tendon can be justified."[13] In the late 1970s Lildholt[14] and Termansen[15] used similar protocols; Lildholt's series showed 11 of 14 patients to be satisfied, and Termansen's series showed 10 of 12 patients to be satisfied.

In 1981, Nistor[16] published the first prospective randomized trial comparing surgical versus nonsurgical treatment of Achilles tendon ruptures. He found that the rate of re-rupture in the surgical group was 4% vs 8% in the nonsurgical group. However, because the nonsurgical patients had a shorter hospital stay, less absenteeism from work, , regained levels of strength similar to those seen in surgical patients, and a had a lower rate of complications, he favored conservative treatment.[16]

In the largest study of 775 patients, the overall complication rate of surgically treated Achilles tendon ruptures was 20%.[6] These complications include skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual anesthesia risks. Problems with wound healing remain the most common and most difficult to manage given the degree of avascularization around the heel cord. Members of the conservative camp point out that the options for soft tissue coverage over the Achilles tendon are limited. Unfortunately, skin grafts will not adhere to an exposed tendon and local flaps may result in an unsightly donor site and an unacceptable scar. Therefore, these large defects often require a microvascular free flap from the forearm, groin, tensor fascia lata, or the latissimus dorsi.

Studies regarding conservative management of Achilles tendon ruptures have been based on protocols involving extended periods of rigid immobilization. Many authors used below-knee casts for 6 to 12 weeks with the casts first being set with the feet in gravity equinus. The cast was then changed at various intervals, placing the foot in greater dorsiflexion at each change. The last change brought the foot to a plantigrade position (Figures 5A and B). Patients eventually were allowed to bear weight with crutches while in the cast and were instructed to work toward full weight bearing at a gradual pace.[5,12,17,18,19] Many authors also used a heel lift for 6 weeks after cast removal.[5,12,16,17,18]

Figure 5.

Casting for nonsurgical treatment of ruptured Achilles tendon. (A) Patient is seated and foot placed in gravity equinus. (B) Below-knee or above-knee cast is placed with foot in gravity equinus. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed St. Louis, Missouri: Mosby, Inc; 1999:826-861.[38]

Figure 5.

Casting for nonsurgical treatment of ruptured Achilles tendon. (A) Patient is seated and foot placed in gravity equinus. (B) Below-knee or above-knee cast is placed with foot in gravity equinus. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed St. Louis, Missouri: Mosby, Inc; 1999:826-861.[38]

Recently, a more functional protocol has been used. Saleh and colleagues[20] compared a group of patients who were placed in a rigid cast for 8 weeks with a group that was placed in a rigid cast for 3 weeks followed by a Sheffield splint for 6 to 8 weeks. This splint is an ankle-foot orthosis that holds the ankle at 15 degrees of plantar flexion and allows controlled motion with physical therapy. The group with the splint gained dorsiflexion motion more rapidly, returned to normal activities quicker, and preferred the splint to the cast. In addition, there was no increased rate of re-rupture. Whether this protocol will influence more surgeons to opt for non-operative treatment remains to be seen.

Surgical Treatment

Despite the resurgence of the conservative camp in the 1970s, surgery has been the first choice of treatment for Achilles tendon ruptures in young fit individuals since the late 1980s. Advances in surgical techniques and new postoperative rehabilitation protocols have resulted in studies showing the advantages of direct tendon repair.[6,17,18,19,21]

With conservative treatment, extensive scarring often fills the gap between the torn tendons. This leads to a lengthened tendon, which, in turn, leads to decreased push-off strength. In separate studies, Helgeland[22] and Inglis[17] and colleagues showed that surgical treatment of Achilles tendon rupture resulted in increased strength. Cetti and colleagues[18] and Haggemark[23] independently showed that direct repair resulted in less calf atrophy when compared with non-surgical treatment. Mendelbaum and colleagues[19] showed that those undergoing direct repair lost only 2.6% of their strength when undergoing isokinetic testing and that 92% of athletes were able to return to their respective sports at a similar level at 6 months postoperatively. Cetti and colleagues[18] also showed a higher number of patients returning to their pre-injury athletic level. In addition, surgical repair appears to significantly increase the strength in those suffering re-ruptures. Those treated surgically for the second time increased their level of strength by 85% compared with a 51% strength gain in those treated conservatively.[3]

Perhaps the most well known benefit of surgical repair is the decreased re-rupture rate. Despite favoring nonsurgical treatment, Nistor[16] noted that those treated conservatively had an 8% re-rupture rate while those treated surgically had a 4% rate. Recent studies show an even greater difference. Cetti and colleagues[18] reported re-rupture rates of 1.4% 13.4% for surgical and conservative repair, respectively. In a meta-analysis by Kellam and coworkers,[21] re-rupture rates were found to be 1% and 18% for surgical and conservative repair, respectively. Even more impressive is a study by Inglis and colleagues[16] who reported that none of the 44 patients receiving direct repair re-ruptured, whereas 9 of 24 patients treated nonsurgically did re-rupture.

In contrast to Nistor's 1981 study,[16] more recent studies[18,24] show an increased complication rate in those treated conservatively. One prospective randomized study reported complication rates of 11.8% in patients treated surgically vs 18% for those treated nonsurgically;[18] 96.6% of the complications in the surgical group were considered minor. Leppilehti and coworkers[24] noted that complications related to surgery did not significantly influence the long term outcome as most of them were minor wound healing problems which eventually healed.

Increased operative treatment also leads to more experience in treating complications effectively. For example, it is now shown that physical therapy can overcome many of the problems associated with adhesions between the repair site and the skin.[6] Moreover, the vast majority of superficial wound infections can be treated effectively with limited weight bearing, oral antibiotics, and silver sulfadiazine (Silvadene).[6] Once the tissue granulates, the wound can simply be treated with wet to dry dressing changes; only in rare circumstances is a local or a free flap necessary.

Those favoring surgical treatment also point out the relatively uncomplicated nature of the procedure. There is no evidence showing that primary augmentation is more effective than simple end-to-end repair in acute tears. Therefore, more extensive procedures using tendon transfers, flaps, or mesh are best left for use with delayed tears, in which the repair will be under tension due to the chronically retracted ends.

Surgical Technique

The patient is placed in the prone position with both prepped feet dangling from the end of the table. By placing the table in Trendelenburg, the feet receive less blood flow. An 8-cm to 10-cm longitudinal incision is made just medial to the Achilles tendon. A posterior lateral incision would place the sural nerve at risk and a mid-posterior incision can result in suture interference from the tendon repair site. After dissecting through the subcutaneous tissues, the paratenon is cut longitudinally with Mayo scissors. As the ruptured ends often have a "mop-end" appearance (Figures 6A-6C), some surgeons will wait one week before repair in order to allow the ends to better consolidate. After juxtaposing the ends, the tendon is sewn together with non-absorbable suture via a Krackow (Figure 7) or Bunnell stitch. Prior to tying the suture ends, the tendon's dynamic resting tension is optimized by comparing it with the control side. A circumferential stitch is used to further strengthen the repair site. After closing the paratenon, the plantaris fascia can be fanned out over the repair site to help prevent adhesions with the undersurface of the skin. The subcutaneous tissue is then approximated with absorbable suture and the skin sewn together in a nylon mattress fashion. A fasciotomy of the deep posterior compartment can facilitate closure in cases with excessive skin tension.[6] This allows for improved closure of the paratenon as well.

Figure 6.

Acute Achilles tendon ruptures. (A) Separation of fragments with lack of tendon fraying. (B) Rupture with marked tendon fraying. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]

Figure 6.

Acute Achilles tendon ruptures. (A) Separation of fragments with lack of tendon fraying. (B) Rupture with marked tendon fraying. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]

Figure 7.

Krackow technique of double-lock suture used in the repair of ruptured Achilles tendon. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]

Percutaneous repair. In 1977, Ma and Griffith[25] described a technique of repair that does not require the healing of a large incision. By placing 6 small stab incisions on the medial and lateral sides of the Achilles tendon, they showed that the tendon could be repaired. Only 2 of the 18 patients experienced minor noninfectious skin complications and none of the patients re-ruptured. Using a similar technique, Fitzgibbons noted good results in all 14 of his patients.[26] In Rowley and Scotland's series, those with percutaneous repair had increased plantarflexion strength and returned to their usual level of activity sooner than did those treated non-operatively with a cast.[27]

Unfortunately, most studies of percutaneous repair report inferior results when compared with open repair. Rowley and Scotland[27] noted a 10% rate of sural nerve entrapment and Klein and colleagues[28] noted a 13% rate. Hockenbury and Johns[29] performed the procedure on cadavers and noted that 60% of the patients had an entrapped sural nerve. They also found that 80% had malaligned stumps. This may account for their further finding that these cadavers had only one half the strength at the repaired site as did those repaired in an open manner. This may explain why the re-rupture rate is higher after percutaneous repair than after open repair.

Currently, percutaneous repair is favored over open operative repair only in patients who have minimal requirements for playing sports, accept a higher risk of re-rupture, desire a re-approximated tendon, and place a high value on their cosmetic appearance. Given the current guidelines, the procedure likely will continue to be performed less frequently then open repair. Therefore, improvements in the technique will also most likely continue to lag.

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