Achilles tendon repair

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Description

The achilles tendon connects the calf muscles to the calcaneus (heel bone) and is one of the important tendons in the human body. The main action of the achilles tendon is foot plantar flexion. Common pathologies include: tendinopathy, tear or rupture. Examples of mechanisms of injury for rupture includes: falling from a height, forceful plantar flexion of the ankle (as in jumping with an extended knee), or using the foot to break a fall if you stumble. Clinically they present with a palpable gap on palpation, increased passive dorsiflexion, lack of heel raise and a positive Thompson Test. Achilles tendon rupture is either managed conservatively with a cast or surgically with an achilles tendon repair.

For more details on Achilles Tendon Rupture visit this page.

Conservative vs surgical intervention

There is much debate in the literature about treatment for achilles tendon rupture with the two options comprising of a conservative or surgical approach. Many studies have shown that the re-rupture rates are higher in cases of non-operative management. More recently studies have demonstrated equivalent or improved rates of re-rupture compare with surgical intervention. However, many people continue to be treated with surgical repair and physiotherapists will continue to see them for post-operative rehabilitation in their clinics.

Visit the achilles tendon rupture page for information on conservative management.

Pre-op

Prior to surgery general oedema reduction interventions should be utilised (Rest, Ice, Compression, Elevation). The surgery will ideally occur within one week of the rupture.

Surgery Description

File:Achilles tendon rupture 2.jpg

Many techniques exist for this surgery, including transverse, medial and longitudinal incisions. The ankle is placed in neutral position and the severed ends of the tendon are sutured together. The surgeon will then take the ankle through complete range of motion to look at the integrity of the repair. A cast is often applied, with the surgical technique determining how long the cast stays on. Many surgeons are now focusing on early weight bearing and passive motion to improve tendon healing. A new minimally-invasive technique involves utilization of the peroneus brevis via two para-midline incisions. The technique reportedly preserves skin integrity over the site most prone to breakdown in a vertical incision, open reconstruction. Another study recommended percutaneous repair in the recreational athlete and in patients concerned with cosmesis, and open repair for all high-caliber athletes who cannot afford any chance of rerupture."

After medical diagnosis of an achilles Tendon Rupture (ATR) different kinds of therapy can be offered and evaluated. These repair methods can be either by surgery or in a non-operative way where the tendon cures in a natural way with support of a brace and rest . The results of a systematic review of Wu, Yaohong, et al (level of evidence 1a) showed that when functional rehabilitation was used, the effect of non-surgical intervention was similar to surgical treatment regarding the incidence of range of motion, a future chance of rerupture, calf circumference and functional outcomes and also the incidence of other complications was reduced. Non-surgical intervention significantly increased the rerupture rate if functional rehabilitation was not considered .

The choice which one will be applied depends on personal factors such as age of the patient, desire to have a sportive life afterwards and the individual preference. Operative repair by sewing the torn ends of the injured achilles tendon together will reduce risk of a future rerupture but wound infection can be a possible complication factor . Therefore younger persons are recommended to choose for the operative repair and elderly and less active patients will be recommended for a more conservative, natural healing process .

There is a difference between surgery for chronic and acute ATR.

Chronic ATR

Fig. 5 : Treatment strategy for chronic achilles tendon rupture

By evaluating the presence or absence of achilles tendon stumps and the gap length of the rupture, different surgical options (V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer) can be selected for tendon repair (figure: 6) Yangjing Lin et al (level of evidence 2b)) . Acute ATR

Due to a high complication rate after open surgical repair, including wound infection, abnormal sensation, adhesion and thrombosis new technics which require much smaller incisions have been developed and are published in specialised literature . Minimal invasive technics and percutaneous repair become more and more common because they reduce the above mentioned complications and have both a good outcome, as described in the literature of Carmont et al (level of evidence 3a) .

There is ongoing controversy about the best post-operative treatment. A few randomised controlled trials (level of evidence 1b) have been published comparing early mobilization with immobilization after surgery. Most studies have shown slightly better results with early mobilisation or no difference in outcome. Anyway most studies agree early functional treatment is recommended .

Post-operative immobilization consists of rest by wearing a protective plaster cast or brace for about 8 weeks. Partial-weight-bearing crutches can be used 6 weeks after surgery, but strenuous sports (such as running) can only be practiced 1 year postoperatively .

More recent studies however tend to an early mobilisation. The objective is to work actively on the recovery, to prevent muscle atrophy and to regain strength and movement after surgery as a tendon requires movement to heal . These exercises are performed in the first 6 to 8 weeks after surgery with a below-knee brace which allows free plantar flexion of the ankle and walking .

The systematic review of Wu Yaohong, et al (level of evidence 1a) concludes that the findings of meta-analyses regarding surgical versus non-surgical treatment for acute achilles tendon rupture are inconsistent. The current best available evidence suggests that a functional rehabilitation is recommended after a non-surgical intervention. If functional rehabilitation can’t be provided by a rehabilitation centre, a surgical treatment may be preferred for the healing of an acute achilles tendon rupture.

Post-op

Early mobilisation following achilles tendon repair has been reported to be beneficial in terms of postoperative recovery and improved tendon vascularity. Dutton describes three phases of post-surgical rehabilitation following achilles tendon repair. 

Phase I

Phase I typically lasts three weeks.

Goals of this phase are as follows:

• Control oedema and protect the repair site
• Minimise scar adhesion and detrimental effects of immobilisation
• Progress to full weight bearing as tolerated/indicated
• Pain 5/10 or less, strength 4/5 all lower extremity muscles except plantar flexors

Phase I interventions include:

• Modalities for pain and oedema
• Stretching of large lower extremity muscle groups, gastrocnemius/soleus added at week 3
• AROM: plantar and dorsiflexion 3x5; 3 times daily; add inversion and eversion at week 2
• Foot/ankle isometrics at week 2; band exercises week 3
• Proprioceptive training for lower extremities; Gait training
• Upper extremity cardiovascular exercise
• Joint mobilisation and soft tissue work, as indicated

Phase II

Phase II typically lasts from post op week 4-6.

Goals for this phase are as follows:

• Normalized gait pattern
• Full ankle ROM
• 5/5 lower extremity strength
• Return to full ADL ability
• Pain reported to be <2/10
• Proprioceptive reactions equal to non-surgical side

Phase II interventions include:

• Ankle flexibility at various knee angles
• Progressive closed kinetic chain lower extremity strengthening
• Cardiovascular progression
• Proprioceptive training on variety of surfaces
• Manual resisted exercises and joint mobilization, as indicated

Phase III

Phase III typically lasts from post op week 6-15.

Goals for this phase are as follows:

• Initiate running program
• Improve balance and coordination
• Increase velocity of activity
• Return to sport

Phase III interventions include:

• Progressive ankle and lower extremity strengthening
• Agility exercises
• Double heel raise/lower progressing to single leg heel raise at various speeds
  A recent systematic review by Brumann and colleagues (2014) identified the most up-to-date rehabilitation protocol for an achilles tendon repair. They summarised their findings with the following guidelines;

Week 0 - 2

• Nil ankle RoM
• Orthosis fixed at 30° of PF
• Progress to full weight bearing (FWB)

Week 3 - 6

• FWB
• Active ankle RoM 0-30°
• Orthosis limited to plantargrade (0° DF) to 30° PF

Week 7+

• Full RoM
• Nil orthosis