Guideline Summary for Open End‑to‑End Repair of Acute Achilles Tendon Rupture
Pre‑operative Considerations
- Patient positioning – The American Academy of Orthopaedic Surgeons (AAOS) recommends placing the patient prone with the foot hanging off the table to allow gravity‑assisted ankle plantarflexion. 1
- Anesthesia – General or regional anesthesia with tourniquet control is advised for optimal operative field exposure. 3
- Timing of surgery – Acute ruptures (< 2 weeks) are ideal candidates for open repair; current evidence does not support delaying surgery for pre‑operative immobilization. 1, 4
Surgical Technique
- Incision and exposure – A posteromedial longitudinal incision is made and the paratenon is incised longitudinally to expose the ruptured tendon ends. 1, 2
- Tendon preparation – If tendon ends are markedly frayed, minimal freshening is performed while preserving overall tendon length. 5
- Assessment of tendon quality – Ensure at least 3–4 cm of healthy tendon on each side for secure suture purchase. 2
- Krackow suture configuration – The suture should exit the tendon approximately 3–4 cm distal to the tendon end to achieve adequate purchase. 2
- Tendon approximation – Sutures are tied with the tendon ends in direct apposition, confirming no gap at the repair site before closure. 2
- Layered closure –
- Post‑incision dressing – Apply a sterile dressing and place the ankle in a posterior splint with the foot positioned in ~20° of plantarflexion. 6, 7
Post‑operative Protocol
Weeks 0‑2: Protected Immobilization
- Weight‑bearing status – Maintain non‑weight‑bearing for 2–3 weeks in a posterior splint or boot with the ankle in plantarflexion. 6
- Suture removal – Remove skin sutures at 2 weeks if wound healing is satisfactory. 3
Weeks 2‑4: Early Protected Weight‑bearing
- Transition to weight‑bearing – Initiate toe‑touch to partial weight‑bearing in a CAM boot or cast with heel lifts that preserve plantarflexion. 6, 7
- Early weight‑bearing benefit – Allowing weight‑bearing ≤ 2 weeks post‑op accelerates return to activities within the first 6 months without increasing rerupture risk, provided dorsiflexion restrictions are respected. 6, 7
- Dorsiflexion protection – Use a device that limits dorsiflexion beyond neutral to safeguard the repair. 6, 7
Weeks 4‑6: Progressive Mobilization
- Range‑of‑motion – Begin gentle ankle ROM exercises by 2–4 weeks, avoiding dorsiflexion beyond neutral for the first 4 weeks. 7
- Full weight‑bearing – Progress to full weight‑bearing in the boot with gradual reduction of heel lifts. 7
Weeks 6‑12: Strengthening Phase
- Protected weight‑bearing – Continue protected weight‑bearing while progressively removing heel lifts. 6
Months 3‑6: Return to Activity
- Sport‑specific training – Commence sport‑specific drills after 12 weeks once adequate strength is demonstrated. 7
- Return to sport – Average time to return to sports is approximately 24 weeks (6 months), individualized based on functional testing. 7
Complications
- Wound infection – Open repair carries a ~6 % risk of superficial wound infection and possible wound dehiscence. 2, 5
- Sural nerve injury – Occurs in about 1.4–2.8 % of open repairs; percutaneous techniques have higher rates (3.2–5.2 %). 2, 3
- Rerupture risk – Patient non‑compliance with postoperative protocols is the primary modifiable risk factor; strict adherence to dorsiflexion limits and weight‑bearing progression is essential. 6
- Deep vein thrombosis – Approximate incidence is 1 %; chemoprophylaxis should be considered for high‑risk patients per institutional protocols. 3
Comparative Outcomes
- Functional outcomes – No significant differences are observed in functional outcomes (return to activity, pain, patient satisfaction) among open, limited‑open, and percutaneous techniques. 1, 2, 5
- Visualization vs. wound complications – Open repair provides direct visualization, reducing the chance of inadequate tendon approximation, but it is associated with higher wound‑related complications compared with minimally invasive approaches. 2