Surgery for a Torn Achilles Tendon

An Achilles tendon tear is a traumatic injury that causes sudden pain behind the ankle. Patients may hear a pop or a snap, and will almost always say they feel as though they have been kicked in the heel (even though no one has kicked them). Patients have difficulty pointing their toes downward, and usually have swelling and bruising that quickly develops around the tendon.

There are several options for torn Achilles tendon treatment. There is not necessarily a best treatment, just a best option for each individual. Therefore, you should discuss the pros and cons of different treatment options for a torn Achilles tendon with your doctor. Treatments range from non-surgical to immediate surgery. Depending on a number of factors, your orthopedic surgeon can help you determine the most appropriate treatment.

Surgery for an acute Achilles tendon tear is seemingly straightforward. The ends of the torn tendon are surgically exposed and sutures are used to tie the ends together. The sutures used to tie together the torn tendon ends are thick and strong, and are woven into the Achilles both above and below the tear.

While the concepts of surgery are straightforward, the execution is more complex. Care must be taken to ensure the tendon is repaired with the proper tension -- not too tight or too loose. The skin must be taken care of, as excessive handling of the soft tissues can cause severe problems including infection and skin necrosis. Nerves are located just adjacent to the tendon, and must be protected to prevent nerve injury.

If surgery is decided upon, it is usually performed within days or weeks of the injury. The idea is to perform the repair before scar tissue has formed, which would make the repair more difficult. Some surgeons may recommend delaying surgery a few days from the initial injury to allow swelling to subside before proceeding with the repair.

Chronic Achilles tendon tears can be more complicated to repair. A tendon that has torn and retracted (pulled back) into the leg will scar in the shortened position over time. Restoring normal tendon length is usually not an issue when surgery is performed within a few weeks of the injury. However, when there has been a delay of months or longer, the treatment can be more complicated.

Several procedures can be used to add length to a chronic Achilles tear. A turndown procedure uses tissue folded down from the top of the calf to add length to the Achilles tendon. Tendon transfers from other tendons of the ankle can also be performed to help restore function of the Achilles. The results of surgery in a chronic situation are seldom as good as an acute repair. However, in some patients, these procedures can help restore function of a chronically damaged Achilles.

There are several complications seen with Achilles surgery that are concerning:

Wound Complications: The most common complications are problems with the skin healing. These problems can happen with anyone, but are especially common and problematic in diabetics and smokers.

Infection: Infections are also problematic, and often the cause of wound healing complications.

Nerve Injury: An important nerve that provides sensation to part of the foot is next to the Achilles tendon. Injury to this nerve can cause numbness in the foot.

Re-Tear: Achilles tendon healing is not a guarantee, and the repaired tendon can be re-torn.

There are many protocols for rehabilitation following surgery for an Achilles tendon tear. Most surgeons use some protection including walking boots or splints, but also start early motion. Studies have demonstrated that motion can be started immediately following surgery, but protection is needed while walking. In patients at higher risk for complications, immobilization with a cast may be continued for several weeks or longer.

In general, most patients return to walking in 4-6 weeks, strengthening after about 8 weeks, and exercising at 3 months. Most patients who are athletes do not return to their sport for about 6 months, and many can take longer to fully recover from Achilles surgery.

_Sources:

_{Reddy SS, et al. "Surgical Treatment for Chronic Disease and Disorders of the Achilles Tendon" J Am Acad Orthop Surg January 2009 ; 17:3-14.}

_{Chiodo CP, et al. "Diagnosis and Treatment of Acute Achilles Tendon Rupture" J Am Acad Orthop Surg August 2010 ; 18:503-513.}