Achilles Tendon Repair

Over the past decade the incidence of acute Achilles tendon rupture has increased, reflecting the greater prevalence of people who are involved in sports, with the highest incidence being in men 30–50 years of age.¹

Treatment of Achilles tendon ruptures is still debated in the literature; there are numerous publications that widely report the advantages, disadvantages and complications of different types of treatment. Generally, these can be grouped into four categories: conservative treatment (classic or functional), open-surgery treatment (with different types of suture, with or without augmentation), percutaneous surgicaltreatment and mini-invasive surgical treatment (using specialised instruments). However, the majority of publications demonstrate that, to date, there is no consensus in terms of the best treatment.^2–5 In particular, the percentage of re-rupture with conservative treatment ranges from 10 to 30%,^6–8 but this rate can be reduced if treatment is performed within 48 hours from injury. ^7,9,10 Good results have been reported with functional conservative treatment followed by ecotomography in subjects in whom the dislocation of the stumps was not above 1cm, the foot was at 90º and the stumps were well-matched when the foot was 20º plantarflexed.¹¹ The rate of re-rupture is clearly reduced (5%) if open surgery is performed.^{5,7,8,12–14} Otherwise, the rate of surgical complications, such as wound dehiscence, infections, sural nerve injuries or cheloid growth, is up to 20%.^{7,8,12,14–17} The rate of surgical wound complications significantly rises to 42.1% if certain risk factors, such as diabetes, smoking or steroidal therapy, are present.¹⁸

Percutaneous and mini-invasive techniques with or without the use of specific instruments limit the rate of open surgical complications; otherwise, the rate of re-rupture is almost 10% and the onset of other complications such as stump malalignment, protracted healing, skin retraction and nodules or sural nerve entrapments are in the order of 13%. ^16,19 Recently, a short-term experience with arthroscopically assisted percutaneous suture – which seems to reduce the rate of complications – has been reported in the literature. ²⁰ Nevertheless, considering reports over the last 15 years, we find that good clinical and functional results are probably due more to early functional rehabilitation than to the kind of treatment or the surgical technique adopted. ^21–26 In fact, it is demonstrated that this allows better alignment of collagen fibres during healing, improvement of the resistance of scar tissue and reduced recovery time. ²⁷ Thus, many different post-operative protocols, more or less aggressive, have been described.

In many cases, these functional or semi-functional protocols are managed with the help of a walker boot. Considering these new experiences, an important suggestion is that the aggressiveness of the post-operative programme should depend on the strength of the suture
applied in surgery and on the type of surgical technique to avoid lengthening of the tendon, prolonging healing or early tendon re ruptures. Undoubtedly, an out-of-date concept is that the knee must be immobilised after surgery to avoid stresses on the suture when the knee is extended; in fact, it has been demonstrated that at 30º tibio–talar plantar, flexion – the mechanical traction effect on the restored tendon – is neutralised, even if the knee is fully extended. ²⁸

After extensive experience, our orthopaedic school believes that surgical treatment results in better functional outcomes with shorter recovery time, even in the presence of major risks of complications. ^19,29,30