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
Prone, all bony prominences well padded.
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)
Paratenon repaired with 2-0 absorbable suture.
Close in layers.
Below-knee bulky compressive dressing with plaster splints holding foot in gravity equines.