Achilles Tendon Repair 27650

Achilles tendon rupture image

Ankle Cross section image

Achilles tendon rupture image

Achilles tendon rupture approach

Achilles tendon incision image

CPT Coding Technique
Indications Complications
Contraindications Follow-up Care / Rehab Protocol
Alternatives Outcomes
Pre-op Planning / Case Card Review References

synonyms:Achilles tendon repair, gastrocnemius tendon repair, heel cord repair

 Achilles Tendon Repair CPT

Achilles Tendon Repair Indications

  • Acute Achilles tendon rutpure: quicker return to work/sport, less atrophy, better range of motion, restore normal tension, decreased re-rupture.  (Nistor L, JBJS63A:394;1981)

Achilles Tendon Repair Contraindications

  •  Relative: lower demand older pt, pts on systemic steroids/methotrexate, IDDM, vascular compromise.

Achilles Tendon Repair Alternatives

  • Non-op treatment: Weight-bearing short leg cast with the foot in a gravity equinus position for 8 weeks.  Cast removed at 8 weeks. Start 2.5cm heel lift and gastric stretching / strengthening.( Lea RB, JBJS 1972;54A:1398)

Achilles Tendon Repair Pre-op Planning

  • Consider limited open repair.  Limited open repairs demonstrate no difference in rerupture rate, sural neuropathy, or calf circumference with less scarring and less postoperative complication as compared to open repair. (Aktas S, Foot Ankle Int. 2009 May;30(5):391),(Gigante A, Knee Surg Sports Traumatol Arthrosc. 2008 Feb;16(2):204).
  • Surgery can be done immediately or delayed 7 to 10 days. Delaying can reduce swelling and allow some organization of the "mop-ends" of tendon allowing restoration of the anatomic length. There is no difference in outcomes if repaired within 30 days.
  • Turn-down gastroc fascial flap augmentation of acute repairs does not improve outcomes (Pajala A, JBJS 2009;91A:1092).
  • If V-Y lengthening is needed.  The length of the V needed is typically 1.5x the length of the defect to be closed.  

Achilles Tendon Repair Technique

  • Pre-op antibiotics.
  • Prone, all bony prominences well padded.
  • Thigh tourniquet.
  • Prep and drape in standard sterile fashion.
  • Posteromedial incision (medial to the medial border of the Achilles). Dissect down to paratenon (deep crural fascia), without making large skin flaps.
  • Paratenon incised longitudinally.
  • Hematoma evacuated, tendon ends debrided.
  • Plantaris tendon passes deep to crural fascia along medial aspect of Achilles, may be used to augment repair.
  • No 2 nonabsorbale suture (Orthocord) placed using Kessler technique. Repairs may be done with Bunnell suture technique, modified-Kessler technique, Krakow locking loop technique, tiple bundle technique (Beskin JL, AJSM 1987;15:1)
  • Knee flexed, foot plantar flexed for suture tying. 
  • Vertical locking circumferential 2-0 absorbable suture placed to augment repair.
  • Augmentation: gastroc fascial turndown(Jessing P, Acta Chir Scand 1975;141:370), plantaris tendon (Lynn TA, JBJS 1966;48:268), or biologic tissue scaffold.
  • Consider Platelet-rich plasma injection. (Sánchez M, AJSM 2007; 35:245)
  • Irrigate.
  • Paratenon repaired with 2-0 absorbable suture.
  • Close in layers.
  • Below-knee bulky compressive dressing with plaster splints holding foot in gravity equines.

Achilles Tendon Repair Complications

Achilles Tendon Repair Follow-up care

  • Post-Op: place in a gravity equinus splint, non-weight bearing
  • 10 day f/u, casted at 10-20º flexion, NWB; Consider functional boot with heel wedge. Consider early weight bearing if repair and tissues are adequate.
  • Differences in weight bearing during initial 8 wks post op does not alter outcomes. (Eliasson P, AJSM 2018;46(10):2492–2502)
  • 4wks; functional boot with 20º heel wedge. WBAT. Begin gentle passive ROM, no passive dorsi flexion.
  • 6-8wks; 1” heal lift, begin active physical therapy:passive stretching, active theraband. Heal lift continued until able to reach 10 degrees of dorsiflexion.
  • Perform stretching exercises prior to commencing any sports permanently. May return to sports at 3-4 months.
  • Achilles Tendon Rehab Protocol.

Achilles Tendon Repair Outcomes

  • Time to recover full function is at least 12 months. (Eliasson P, AJSM 2018;46(10):2492–2502)

Achilles Tendon Repair Review References

  1. Eliasson P, AJSM 2018;46(10):2492–2502
  2. Keene JS, in Delee and Drez Orthopedic Sports Medicine, 2nd ed, 2003
  3. Calhoun JH, in Masters Technique Foot and Ankle, 2nd ed, 2002
  4. Saltzman CL, JAAOS, 1998;6:316
  5. Myerson Instr Course Lect 48:211;1999