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Surgical Repair of Achilles Tendon Rupture

Achilles Tear Surgery

In the past the patient was put in a plaster cast with the foot pointing down and it was hoped that the tendon healed well enough to provide function. Surgery was considered less suitable because there was an increase risk of infection particularly as the wound in the leg needed to be 20 cm long to get proper access to the tendon. The surgery can now be carried out through very small incisions with a much lower risk of infection.

There is a body of opinion that surgical correction of the ruptured tendon is almost always necessary. This is performed in order to regain the maximum strength of the Achilles, as well as the normal pushing-off strength of the foot. The strength of the muscle depends on the correct tension between the muscle and the tendon. The only way that the correct tension on the tendon can set is by accurately repairing the tendon ends.

Achilles-Suturing


The Achilles Tendon generally tears about 5 cm above the heel attachment. The ends separate from each other a bit like cutting the ends of an elastic band.
These ends are pulled together at the surgery and stitched with strong sutures.

If the rupture has been present for many months, there is no urgency to do the surgery, but one really should not wait too long, since the Achilles tendon continues to pull up into the leg and the gap between the tendon ends gets larger, making the surgery more difficult.



Acute vs Chronic Tear

An Achilles tear can be considered acute if it is less than a few weeks since the injury occurred. Ideally it should be operated on quickly. Sometimes however, especially with amateur athletes and the so-called ‘weekend-warriors’ over the age of 30, the problem is sometimes missed and it is only after several weeks that a diagnosis of ruptured Achilles is made. These chronic tears almost always require surgery as the ends have separated and the muscle has shortened which means that conservative management is not likely to produce a satisfactory result.
Achilles -percutThe type of surgery performed depends on the size of the gap between the tendon ends and the extent of separation that is present.
In an acute injury the separation is minimal, then the tendon ends can be stitched together. If the separation is more significant, then other procedures need to be performed.
As the gap gets bigger, the options then range from using a strip of the lining of the existing Achilles, using another tendon as a tendon transfer, or even using an Achilles tendon graft which comes from the tissue bank.

A tendon transfer is only used when there is a massive gap present, or the Achilles has been ripped off its’ attachment on the heel bone. When it comes to using a different tendon to substitute for the Achilles there are a few tendons which can theoretically be used, but the tendon transfer which is preferred uses the second strongest muscle in the leg, the muscle to the big toe (the flexor hallucis longus).
The disadvantage of this operation is that the flexor hallucis muscle is not as strong as the Gastrocnemius which powers the leg. Nonetheless, patients are able to push off fairly comfortably with the tendon transfer and can even participate in some sporting activities. This operation can be performed through a very small incision on the back of the ankle although there are risks of damage to a nerve and local blood vessels with this technique.




After Surgery

boot

The individual surgeon has his own preferences for how quickly the patient is allowed to put weight through the leg. In the past the leg could be immobilised post op in a plaster cast for a few weeks but that does not always happen nowadays. Current thinking is that early weight bearing encourages a better healing of the repair with much less muscle wasting and therefore better function. So walking is begun in a removable boot which controls the range of motion at the ankle.


Here is a quote from the surgeon who operated on David Beckham – Dr Orava said: “Today we allow patients to do motion earlier than before. In this case we try to get motion back as soon as possible. The operation takes less than one hour. [After the] first month, there can gradually be more and more motion and muscle contractions, and very gradually [shifting] from light training to harder training in the second month. After that, one is usually able to walk and maybe start running lightly after two months if everything goes fine. All this depends on the type of tear.”
“Top athletes usually heal well but it’s a few months until you are back at the same level as you were before. I don’t think it is a big difference to be [aged] 25 or 35, it will be three, four, five months. Most of these patients come back at the same level, even in a top soccer player.”


Japanes surgeon Yotsumoto and his colleagues have applied a side-locking loop technique of their own design for the core suture, using braided polyblend suture thread, with peripheral cross-stitches added. Their patients started active and passive ankle mobilization from the next day, partial weightbearing walking from 1 week, full-load walking from 4 weeks, and double-legged heel raises from 6 weeks after surgery. The results showed range of motion recovery equal to the intact side averaged 3.2 weeks. Double-legged heel raises and 20 continuous single-legged heel raise exercises were possible at an average of 6.3 weeks and 9.9 weeks, respectively. The patients resumed sports activities or heavy labor at an average of 14.4 weeks. There were no complications.



Rehab post op

Early Rehab is all about maintaining and regaining range of movement at the ankle especially dorsiflexion (the foot up towards the front of the leg)
Rehab is then about recovering strength in the tendon and calf muscles while not putting the repair at risk.
As mentioned earlier walking is started in the boot very quickly and this helps to maintain the normal muscle control.
Patients work with elasticated bands as resistance to increase strength and can use static bicycles to maintain aerobic fitness.
Balance exercises are used to recover normal neurological patterns and improve proprioception.
Swimming helps aerobic fitness and allows weight bearing to take place with some of the bodyweight supported by the buoyancy of the water.
Eccentric exercises (lowering down from up on toes) are essential because this is how the calf and Achilles tendon function normally.
After the boot is removed walking is progressed to fast walking and then gentle running.
The speed and intensity of the running is gradually increased.
Sports specific drills and training are introduced as soon as possible – this make it easier to return to sport quickly.

Other Achilles Related Posts

Anatomy of the Achilles Tendon
Achilles Tendon Rupture
Ruptured Achilles Tendon and Non-Surgical Treatment
David Beckham's Achilles Tendon Rupture
Calf Exercises - Achilles Tendon Stretches
Function of the Achilles Heel Tendon

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  8. Bolton Wanderer’s Sam Rickets’ Achilles Tear | Physiotherapist Hamilton Says:

    [...] Achilles Tendon Surgery Your Achilles Tendon typically tears about 5 centimetres above your hindfoot attachment. Your edges split from each other somewhat comparable to chopping the ends of an elastic band. These edges are pulled together in the surgical procedure as well as stitched with sturdy stitches. Previously the affected person has been put in a plaster cast with the foot pointing straight down and so it was hoped that the tendon cured well enough to deliver functionality. Surgical treatment has been deemed significantly less suitable due to the fact clearly there was an increase danger of infection particularly since the wound in the lower leg needed to be 20 cm in length to have proper entry to the tendon. The surgery can be performed through very small incisions which has a dramatically reduced chance of an infection. [...]

  9. Bolton’s Welsh International Sam Rickets’ Achilles Tendon Injury | Bothwell Physiotherapy Says:

    [...] Achilles Tendon Surgery The Achilles Tendon usually ruptures around 5 cm higher than the heel attachment. The edges separate from one other a bit like cutting the ends of an elastic band. These edges are pulled together at the operation and stitched using sturdy sutures. In the past the patient was put in a plaster cast with the foot aiming down and it was hoped that the tendon cured well enough to deliver functionality. Surgical treatment was thought to be much less appropriate due to the fact there was an increase risk of an infection especially since the wound in the lower-leg needed to be 20 centimetres long to get proper access to the tendon. The surgery is now able to performed through very small incisions which has a far lower risk of infection. [...]

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