JFAS 31(5): 440-445, 1992

A New Method of Repair for Rupture of the Achilles Tendon

Rupture of the Achilles tendon requires prompt and appropriate treatment to prevent
prolonged or permanent disability. Although the literature abounds with evidence
supporting both conservative and surgical treatment, more recent studies report lower
rerupture and complication rates with surgical repair. The development of ligament
anchoring devices has led to new methods of repair for ligament and tendon injuries. A
modification of the Lindholm technique that utilizes these devices is presented.

David S. Chen, DPM1

Stuart J. Wertheimer, DPM, FACFS2

Since Ambrose Pare first described surgical repair of the ruptured tendo Achillis in 1575
(1), controversy has existed concerning the merits of surgical versus conservative
treatment. Within the past decade, numerous studies have compared these two treatment
regimens producing little convincing evidence favoring one side or the other (2). Progress
in surgical technique and technology has invariably led to fewer complications following
surgery. More recent reports acknowledge that primary repair of total Achilles rupture
yields lower rerupture and complication rates compared with conservative therapy (2).
Recently, devices permitting anchoring of ligaments to osseous tissues have been
described (3). Use of this technology has led to new methods of repair for tendinous and
ligamentous pathology. A modification of the Lindholm procedure utilizing the Mitek3
ligament anchoring device is presented along with a review of the literature illustrating
the clinical signs and symptoms of a tendo Achillis rupture.

Mechanism of Injury

Total rupture of the tendo Achillis may be caused by direct or indirect trauma.
Direct injuries are predominantly represented by lacerating incidents. Continous pressure,
as can be caused by the top of a ski boot, has also been reported (4). More commonly,
indirect forces contribute to the majority of injuries.
Arner and Lindholm (1) described three main types of indirect trauma capable of
causing rupture. The first type involves a push off with the weightbearing forefoot with
extension at the knee, such as the start of a sprint, running, or certain types of jumps. The
second type involves sudden unexpected dorsiflexion of the ankle, such as slipping on a
stair or ladder, stumbling into a hole, or falling forward suddenly. The third type involves
violent dorsiflexion of a plantarflexed foot that occurs when jumping or falling from a
height and landing with the foot plantarflexed (1).

Pathology
 Most ruptures of the tendo Achillis occur in three locations. The first location is
the musculotendinous junction. The second site is the central portion of the tendon, and
the third is its osseous insertion (5). The most frequent site reported is located 2 to 5 cm.
proximal from its insertion. This site has been demonstrated to have a reduction in its
blood supply with increasing age, particularly after the 3rd decade of life (6).
Corticosteroid injections have often been implicated as etiological agents in
tendon rupture. Experimental models have demonstrated significant weakening of the
tendon after injections of corticosteroids (7). However convincing this evidence is, the
role of corticosteroids is probably an indirect one. These injections may relieve the
symptoms of a partial rupture, leading to increased activity which may, ultimately, result
in complete rupture. A combination of excessive unexpected stress with increased
degenerative changes, resulting from hindered vascular supply, probably all contribute to
the rupture process. No singular element has definitely been demonstrated to account for
this type of injury.

___________________________________________________________
From the Department of Podiatric Surgery, St. John Hospital-Macomb Center,
Mt. Clemens, Michigan.
0449/2544/92/3105-0440$03.00/0
Copyright © 1992 by The American College of Foot Surgeons

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Diagnosis

Often the afflicted individual is a male in his 3rd or 4th decade. He leads a
sedentary lifestyle, with the injury occurring while engaged in some type of sporting
activity. Typically the patient presents with pain and swelling in the posterior aspect of
the distal leg and ankle. The sensation of being kicked or "struck by a bat" in the back of
the leg may be described. This may be accompanied by an audible snap or other sound.
The degree of pain following the injury may range from mild to severe. Occasionally, the
degree of discomfort following injury may be so negligible that the patient may not seek
medical attention for an extended period of time. Eventually, this patient seeks medical
attention due to difficulty in climbing stairs and is unaware of the severity of his injury.
Physical examination often reveals a palpable defect or delve in the region of the
rupture that may be visually apparent. Depending on the amount of time elapsed since the
injury edema, ecchymosis, and tenderness upon palpation may be present. If the plantaris
tendon is still intact, it may often be palpated as a string-like cord.
Active plantarflexion may be present. However, it will be greatly decreased. This
flexion is attributed to the long flexors, peroneals, and the tibialis posterior. The patient
not only will be unable to lift his heels off the ground while standing, but will also be
unable to push off during gait. Compression of the calf at the level of the myotendinous
junction will fail to cause plantarflexion at the level of the ankle joint. This is referred to
as a positive Thompson test (8).
 Radiographic examination will reveal disruption of the normal contours of
Kager's triangle. Kager's triangle refers to a normal fat pad that is viewed in the lateral
projection of the ankle. It is bordered by the tendo Achillis posteriorly, the superior
surface of the calcaneus, and the flexors of the deep posterior compartment anteriorly (9).
In total rupture of the Achilles tendon, the distal segment of the posterior wall will be
disrupted.

Figure 1. Incision revealing frayed spaghetti appearance of torn Achilles tendon.

The sural nerve is retracted utilizing a Penrose drain.

Figure 2. The frayed and necrotic portions of the ruptured tendon are sharply
resected.

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Additional changes included narrowing of Kager's triangle, swelling at the tendon

ends, and skin indentation (10). Toygar (11) described an angle that is formed by the
depression in the skin and soft tissue overlying the Achilles tendon. Normally, this
depression measures 110 to 130 degrees. With rupture, the angle increases to 130 to 150
degrees.

Treatment

Lea and Smith (12) described the application of a well molded short leg cast with
the ankle placed in approximately 10 degrees of plantarflexion. The cast is left on for 4 to
8 weeks. The patient is then given crutches and allowed to bear weight as tolerated. After
removal of this cast, full weightbearing is permitted with a 2.5-cm heel lift. This lift is
gradually decreased by 0.5 cm. every 2 weeks until 10 degrees of ankle dorsiflexion is
achieved.
Surgical treatment can be divided into three categories depending on the extent of
the defect after removal of necrotic and degenerated tendon ends (13). Defects less than 3
cm. can be repaired with a simple end to end anastomosis. Those that are 3- to 6-cm. in
length may be repaired with the use of autogenous tendinous flaps and grafts. This repair
may also be supplemented by the use of synthetic graft material such as synthetic mesh,
carbon fiber, and xenograft. Defects greater than 6 cm. will require a gastrocnemius
recession in order to sufficiently lengthen the tendon.
The use of the Mitek ligament anchoring device presents an alternative to the
Bunnell4 pull-out suture technique. The device remains within the calcaneus thereby
lessening the probability of postoperative complications such as infection and premature
loosening of the suture. Surgical treatment is followed by application of an above-the-
knee cast with knee joint flexed at 20 to 30 degrees and the ankle plantarflexed at 10 to
20 degrees.
 Figure 3. Photograph demonstrating resection of the ends of the ruptured tendon.

Figure 4. Mitek device with accompanying anchoring driver.

Figure 5. Mitek components (from top to bottom): drill sleeve, drill, driver,
suture, and anchor.

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This stabilization is removed after 4 weeks and a short leg cast is applied with the ankle
plantarflexed moderately. After 8 additional weeks, the cast is removed and the patient is
placed in a program of physical therapy consisting of mobilization and stretching
exercises. The use of heel lifts is recommended during the initial weightbearing period.

Case Report

A 45-year-old white male presented to the emergency room of Saint John

Hospital-Macomb Center complaining of weakness in his right leg, which began while
participating in a softball game. The patient related that he had been playing softball with
his son and was running around the bases when he felt a snapping sensation like that of
someone hitting the back of his right leg with a bat. He related difficulty in walking and
mild pain in the back of his right leg.
Physical examination revealed edema in the posterior aspect of the right leg with
a palpable defect approximately 3 cm. proximal from the insertion of the tendo Achillis.
A positive Thompson test was elicited. A significant decrease in active plantarflexory
ability was noted in the right leg compared with the left. Radiographic examination
revealed obscuration of the Achilles tendon in the area of the physical defect with
disruption of Kager's triangle. Based on these findings, a diagnosis of complete rupture of
the tendo Achillis was made.
After discussion of surgical and conservative options, the patient consented to
surgical intervention.

Figure 6. O-Mersilene suture is passed in a Bunnell fashion through the proximal

portion of the tendo Achillis after both Mitek devices are anchored in the calcaneus.

Figure 7. Two strips of the aponeurosis are reflected off the underlying complex
in the fashion described by Lindholm (14). An additional absorbable suture is utilized in
a Bunnell fashion to reinforce the anastomosis.

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The following morning, the patient was brought to the operating room and placed in a
supine position on the table. After administration of anesthetic agents, the patient was
placed in a prone position. Several layers of cotton padding were placed around the right
thigh and a pneumatic tourniquet was applied. After exsanguination of the right leg
utilizing elevation and overlying elastic bandage, the tourniquet was inflated to 400 mm.
Hg pressure.

Operative Technique

A 20-cm. longitudinal incision was placed in the posterior aspect of the right leg.
This was deepened to the level of the deep fascia overlying the tendo Achillis with care
taken to clamp and cauterize all vessels as encountered. The sural nerve was identified
and gently retracted from the surgical site. The paratenon was identified and incised
longitudinally to reveal a rupture of the tendon approximately 3 cm. proximal from its
osseous insertion. The ruptured ends were swollen and frayed into a spaghetti-like
appearance (Fig. 1). These were sharply resected to the level of healthy tendon and the
resulting defect measured approximately 4 cm. in length (Figs. 2, 3).
A 2-0 Mersilene5 suture was loaded onto a 2-0 Mitek anchor (Figs. 4, 5).
Utilizing appropriate instrumentation, the Mitek anchor was placed in the lateral aspect of
the superior surface of the calcaneus. The suture was then loaded onto Keith needles and
passed through the proximal portion of tendon in a Bunnel fashion. A second Mitek and
2-0 Mersilene suture was then placed within the medial aspect of the superior surface of
the calcaneus and tied into the other suture with the foot held at a slightly plantarflexed
position (Fig. 6). A 2cm. gap was still visible.
Utilizing the method described by Lindholm (14), two 1 × 0-cm. strips of the
gastrocnemius aponeurosis were reflected off the underlying muscle with care taken to
keep their distal origins intact (Fig. 7). Utilizing a number fifteen Bard Parker surgical
blade,6 incisions were made through the muscle-tendon complex at the level of their
distal origins, and the two strips were passed anteriorly through these incisions.
Incorporating 2-0 absorbable sutures, these strips were wrapped around the medial and
lateral aspects of the gapped portion, with care taken to keep the smooth side facing the
subcutaneous layers between the posterior aspect of the leg and the underlying tendo
Achillis. They were crossed over each other and then sutured into the distal portion of the
ruptured tendon. The knots were kept away from the posterior surface (Fig. 8).
The donor sites from which the tendinous strips were harvested were then
reapproximated utilizing absorbable sutures in a simple interrupted fashion. The repaired
rupture was then reinforced with additional absorbable sutures placed in a series of
simple interrupted sutures (Fig. 9).
The paratenon and skin layers were reapproximated utilizing absorbable sutures
and a sterile dressing was then placed around the right leg, followed by release of the
tourniquet. A synthetic above-the-knee cast was applied with the patient's right knee
flexed 30 degrees and foot plantarflexed 20 degrees. Subsequently, the patient was taken
to the recovery room and discharged when all vital signs were stable and body systems
were functioning normally. The patient was given crutches with instructions to remain
nonweightbearing on the right leg. A prescription was written for Acetaminophen with
Codeine, for control of postoperative pain.

Figure 8. Each strip is passed anteriorly through the tendon and wrapped around
the defect in a spiral pattern. The smooth portion of each strip is placed facing the
subcutaneous layer and the ends are sutured into the distal portion of tendon. The harvest
sites are then reapproximated with absorbable suture.

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The cast was removed 4 weeks following surgery, at which time, a short leg
synthetic cast was applied. The patient was told to remain nonweightbearing in this cast
utilizing crutches. At 8 weeks following surgery, the patient's cast was changed and he
was allowed to bear weight to tolerance. At 12 weeks, the cast was removed, and the
patient was allowed to bear weight with a 2.5-cm. heel lift in his right shoe. This lift was
decreased by 0.5 cm. at 2-week intervals.
The patient was placed in a physical therapy regimen consisting of passive and
active range of motion exercises, as well as stretching exercises to increase the
dorsiflexory ability within his right ankle. At the patient's 6- and 12-month postoperative
check, he related no pain or discomfort. Additionally, he related no difficulty in
ambulation or in climbing stairs. The patient is now able to dorsiflex his right foot to
approximately 5 degrees and is able to work at his pre-injury level.

Conclusion

The Mitek system has been utilized to repair four patients with total Achilles
rupture at Saint John Hospital-Macomb Center. There have been no postoperative
complications to date. The Mitek anchoring system allows a novel modification of the
Lindholm procedure for total Achilles rupture that allows for technical simplicity. The
anchoring units are made of a titaniumnickel alloy, which possesses excellent long-term
biocompatibility. This method of repair for rupture of the Achilles tendon utilizes the
latest advances in ligament and tendon repair, and represents an improvement over the
Bunnell pull-out type suture. Although complete ruptures of the Achilles tendon remain
problematic, prompt surgical repair appears to allow the best prognosis.

Figure 9. Line drawing demonstrating the completed repair.

References

1. Arner, O., Lindholm, A. Subcutaneous rupture of the Achilles tendon. A study

of 92 cases. Acta Chir. Scand. (Suppl.) 239:1-7, 1959.
 2. Wills, C. A., Washburn, S., Caiozzo, V., Prietto, C. A. Achilles tendon rupture;
a review of the literature comparing surgical vs nonsurgical treatment. Clin. Orthop. Rel.
Res. 207:156-163, 1986.
3. Pederson, B., Tesoro, D., Wertheimer, S., Coraci, M. Mitek anchor system: a
new technique for tenodesis and ligamentous repair of the foot and ankle. J. Foot Surg.
30:48-51, 1991.
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a case report and discussion of conservative vs surgical repair. J. Foot Surg. 22:32-39,
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deposit in the Achilles tendon. Acta Chir. Scand. 116:251-259, 1959.
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biomechanical and microscopic correlative study. Am. J. Sports Med. 4:11-19, 1976.
8. Thompson, T. C. A test for rupture of the tendoachilles. Acta Orthop. Scand.
32:461-472, 1962.
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695, 1939.
10. Goldman, S., Linscheid, R., Bickel, W. Disruptions of the tendoachilles;
analysis of 33 cases. Mayo Clin. Proc. 44:28-35, 1969.
11. Toygar, O. Subkutane ruptur der achillessehne. Helv. Chir. Acta 14:209-218,
1947.
12. Lea, R. B., Smith, L. Nonsurgical treatment of tendoachillis rupture. J. Bone
Joint Surg. 54A:1398-1410, 1972.
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surgical repair techniques. J. Foot Surg. 29:361365, 1990.
14. Lindholm, A. A new method of operation for subcutaneous rupture of the
Achilles tendon. Acta Chir. Scand. 117:261-268, 1959.

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