What are the surgical options for Achilles‑tendon pathology and the preferred treatment for an acute midsubstance rupture in a healthy adult?

Surgical Options for Achilles Tendon Pathology

Preferred Treatment for Acute Midsubstance Rupture

For acute midsubstance Achilles tendon ruptures in healthy adults, percutaneous or limited open repair techniques are preferred over traditional open repair, as they provide superior patient-reported outcomes, faster return to activity, and significantly fewer wound complications while maintaining comparable functional results. 1

Surgical Technique Options

Percutaneous Repair

• Patients achieve significantly higher physical and mental component scores compared to open repair 1
• Results in significantly less wound breakdown, delayed healing, and fewer scar adhesions 1
• Associated with more wound puckering compared to open techniques 1
• Modern percutaneous knotless repair shows no significant difference in patient-reported outcomes (FAAM ADL scores: 99 vs 99 points) compared to open repair at 5-year follow-up 2
• The Tenolig® percutaneous device demonstrates a low re-rupture rate of 2.11% with minimal scar complications 3
• The Achillon® mini-open system shows an overall complication rate of 8.3%, including 3.2% re-rupture rate, 2% incision problems, and 1.2% sural nerve injuries 4

Limited Open Repair

• Allows return to normal walking, stair climbing, and sports in significantly less time than standard open repair 1
• Significantly fewer severe wound infections and superficial infections compared to traditional open repair 1
• Provides direct visualization while minimizing soft tissue disruption 1

Traditional Open Repair

• Higher rates of wound complications and infection compared to minimally invasive techniques 1
• May be preferred in delayed presentations or when tissue quality requires direct visualization 5
• Associated with 4.9% complication rate versus 1.6% for nonoperative treatment 5
• Provides lower re-rupture rates (2.3%) compared to nonoperative treatment (3.9%) 5, 6

Surgical vs. Nonoperative Considerations

• Operative repair significantly reduces re-rupture risk (Risk Ratio 0.36,95% CI 0.21-0.64) but carries higher wound complication rates 6
• Surgical repair allows 88% of patients to return to baseline activity by 5 months postoperatively 5
• When early range-of-motion protocols are used, operative and nonoperative outcomes become equivalent with similar re-rupture rates 5

Post-Operative Management Protocol

Immediate Post-Operative Period

• Immobilize ankle in maximum plantar flexion using a fixed-ankle walker-type device for 2 weeks 1, 5
• The walking boot must limit dorsiflexion to protect the healing tendon 1

Early Mobilization (Critical for Optimal Outcomes)

• Begin early protected weight bearing within 2 weeks following repair 1
• Early weight bearing protocols result in quicker return to activities during the first 6 months compared to traditional non-weight bearing 1
• Begin mobilization by 2-4 weeks using a protective device 1
• By 12 months, outcomes (pain and function) are similar regardless of early or delayed weight bearing protocols 1

Complications and Risk Management

Sural Nerve Injury

• Can occur with both percutaneous and open techniques 1
• Incidence approximately 1.2% with mini-open systems 4

Wound Complications

• Significantly reduced with percutaneous and limited open techniques compared to traditional open repair 1
• Superficial skin ulcerations occur in approximately 2% of percutaneous repairs 3

Re-rupture Prevention

• Patient compliance with the prescribed protocol is crucial to prevent re-rupture 1
• Non-compliance with protective devices significantly increases re-rupture risk 1
• Smoking and BMI over 25 kg/m² are risk factors for initial rupture 3

Thromboembolic Complications

• Deep vein thrombosis requires monitoring in all surgical patients 1
• Superficial venous thrombosis occurs in approximately 2% of cases 3

Common Pitfalls to Avoid

• Undertensioning or overtensioning the repair - check resting tension intraoperatively by sterilely draping both legs for comparison 5
• Failure to close the paratenon layer - this causes scarring of skin and surrounding tissues; make a relieving incision on the deep surface of the paratenon 5
• Leaving suture knots on the dorsal side - may aggravate the skin 5
• Poor suture management - leads to tangling during repair 5