Minimally-Invasive Surgical Repair for Achilles Tendon Ruptures

Achilles tendon ruptures are quite common in the general population.  Most happen with athletic activities that require sudden bursts of muscle power in the legs.  Patients report the rupturing sensation as being similar to a kick to the heel or being hit with a tennis ball or racquetball in the heel.  They will have swelling, followed by bruising and a weakness that affects walking.

Physical examination of the patient will most often provide the diagnosis.  The Thompson test will be positive in patients with a tear.

In this video of the Normal Thompson test, the foot moves as the calf is squeezed, indicating that the achilles tendon is intact.

In some instances, MRI or ultrasound will aid in confirming the tear. Once the diagnosis is made, patients have 2 treatment choices: prolonged casting or surgery.  Surgery has two major benefits over cast treatment. The first is a 3x-10x lower rate of re-tearing the tendon in the future, and the second is that it is more likely to reestablish the correct length of the tendon, which is important in achieving near-normal push-off strength when finally healed.  Surgery has two potential complications as well:  wound healing and scar adhesions (when the skin sticks to the tendon).  Both can be directly correlated to the amount of surgery and the length of the surgical wound.

For those patients who choose surgery, minimally invasive achilles tendon surgery can decrease both of these potential complications while achieving the goals of surgical treatment. The surgery is performed through an inch-long incision where the tendon ends are located.

A specially-designed suture device is then passed up and around the tendon, which guides sutures into the tendon and pulls them into the small incision:

 
 

In this video, the sutures are pressed to "lock" into the tendon, The foot can be seen moving when they are "locked."

 

The sutures are then tied so the tendon ends meet, and when compared to the other leg, the foot and ankle should be in the same position.  This means that the correct length of the tendon has been achieved. The wound is then closed:

One week after the surgery, they begin motion exercises.  This helps reduce tendon adhesions and orient collagen (fibers of the tendon) into a stronger configuration.  Over time, more motion, gentle strengthening, and eventually walking and running are added to the therapy program. To date, patient satisfaction for this technique is high and the complication rate is extremely low.

Comments by Jonathan T. Deland, MD, Chief of the Foot & Ankle Service at Hospital for Special Surgery
As it has been well pointed out in this article by Dr. Elliott, who has performed many of these procedures, minimally invasive Achilles repair offers a smaller incision, less chance of a wound complication, and is a technique we are employing because of these advantages.  It has been presented in an article in the Journal of Bone and Joint Surgery.

We are assessing the results, which are quite encouraging.  It is not necessarily for every patient, as the condition of the tendon - or the ability to get a good hold on the tendon - needs to be assessed at the time of the repair. The surgery and rehabilitation can be adjusted depending on these factors. The minimally invasive technique has been used quite successfully in patients at Hospital for Special Surgery, and it is a very good consideration for repair of the Achilles tendon.

Updated: 6/30/2014

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