JFAS 34(3): 262-265, 1995

A Severe Acute Achilles Rupture and Repair

An unusual type IV rupture is described, whereby the Achilles tendon was ruptured in
two places. This required several innovative techniques to repair this injury, which are
described herein. The patient recovered uneventfully and returned to his exercise
activities in 3 months.

Gerald T. Kuwada, DPM, FACFAS1

Most acute tendo-Achillis ruptures in the author's experience are classified as types I to
III (1, 2). Type IV ruptures, or a defect >6 cm, are commonly seen with delayed tendo-
Achillis repair (1, 2). Before this classification system (Table 1), there was no other
simple way of describing the extent of the Achilles rupture and applying it to the
operative procedures necessary to correct the injuries. Recently, a patient presented with
an acute Achilles tendon injury. Clinically, it was determined that the Achilles tendon
had been completely ruptured, because he could not perform a toe rise. With the patient
in a prone position, his calf muscle was squeezed, and there was no plantarflexion
observed. A large palpable defect was noted, and the posterior muscle group was 3/5.
Although the Achilles was completely ruptured, the patient still had <50% strength with
plantarflexion, which was attributed to his flexor tendons. This is unusual, and the author
had never clinically observed this finding before. Admittedly, it was clinically confusing;
however, based on the author's extensive experience with Achilles ruptures, a definitive
diagnosis of complete Achilles rupture was made. Intraoperatively, the rupture was
classified as a type IV. During the repair, the author determined that the Achilles tendon
was ruptured in two different locations. This was highly unusual, because the repair
proved to be challenging and required several innovations from previously described
repair techniques (3-5).

Case Study

A 47-year-old Asian-American male presented to the author for a second opinion

regarding an injury to his left Achilles tendon. While playing volleyball several days
before, he felt as though someone had kicked him in the back of the lower leg. He stated
he felt immediate, sharp pain in the lower leg. He tried to continue playing, but realized
the injury was severe. Ten years earlier, he had ruptured the right Achilles tendon during
sports and was placed in a cast for many months, followed by physical therapy. He stated
it took 2 years before he was able to walk and exercise. Currently, the right Achilles
tendon is weak, which allows him to exercise mildly. His past medical, social, and family
histories were noncontributory to the acute injury.
TABLE 1. Definition of rupture classifications
——————————————————————————
Type I: This is a partial rupture of the Achilles tendon of >25%, which is
treated by cast immobilization and physical therapy.

Type II: After the Achilles tendon rupture's necrotic, friable ends are excised,
a defect of <3 cm. is measured. An end-to-end anastomosis is
performed to repair this rupture.

Type III: After the Achilles tendon rupture's necrotic, friable ends are excised,
a defect between 3 and 6 cm. is measured. Either a gastrocnemius
recession, or an autogenous graft flapped to connect the ends of the
ruptured Achilles tendon with an end-to-end anastomosis, are
performed to repair this defect. A synthetic mesh may be necessary
to augment the repair and is placed on the inferior aspect of the
Achilles tendon, away from the adipose and skin to avoid exuberant
scarification.

Type IV: After the Achilles tendon rupture's necrotic, friable ends have been
excised to good healthy tendon, a defect measuring >6 cm. is noted.
A gastrocnemius recession, and an autogenous graft flapped to
connect the ends of the ruptured Achilles tendon, and an end-toed
anastomosis are performed to repair this large defect. A synthetic
mesh may be used to augment the repair at the autogenous graft site.
—————————————————————————
All patients with types I to IV ruptures are cast in a 90° below-the-knee
nonweightbearing
cast for 3 to 4 weeks, followed by a 90° below-the-knee weightbearing cast for 3 to
6 weeks. Several months of physical therapy are recommended.

____________________________________________________________
From the Green River Surgical Residency Program, Renton, Washington.
1067-2516/95/3403-0262$3 00/0
Copyright ©1995 by the American College of Foot and Ankle Surgeons

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Review of systems was within normal limits, with the exception of the injured lower
extremity.
Lower extremity examination revealed moderate edema, ecchymosis, and mild
erythema along the lower one third of the left Achilles tendon. Neurovasculature
evaluation revealed pedal pulses, capillary plexus filling time, epicritic sensations, deep
tendon reflexes, and Achilles and patellar reflexes were within normal limits and
symmetrical, with the exception of the left ruptured Achilles tendon. Musculoskeletal
examination revealed all muscle groups were 5/5, except the left Achilles tendon that was
3/5, attributed to, in part, his flexor tendons. He could not perform a toe rise, although he
could plantarflex his foot without any resistance.
A 3-cm. defect was palpable and was also 3 cm. from the insertion of the Achilles
tendon. There was a positive Thompson test (when the patient was prone and the calf
muscle was squeezed, no plantarflexion was noted). The defect was painful to touch. No
radiographs or magnetic resonance imaging scans were ordered because the defect was
significant. Despite the confusing clinical presentation, the author felt it was not
necessary. A diagnosis of complete Achilles rupture was made.
Discussion ensued regarding his treatment options. The patient expressed his
desire to continue exercising after the injury has healed, but within a shorter period of
time than 2 years, which was his previous experience with cast immobilization. After
thorough discussion of the possible risks, complications, postoperative care, and
prognosis, the patient elected to proceed with surgical repair.

Operative Report

The patient was transported to the operatory and placed in a prone position after
he had been intubated by the anesthesiologist. The foot and lower leg up to the knee were
prepared using povidone-iodine and rinsed with isopropyl alcohol. The foot and lower leg
were draped exposing the surgical site.
A 25-cm. longitudinal incision was made from the posterior calcaneus to the
myotendinous junction of the gastrocnemius-soleus muscle. The incision was carefully
dissected through the various subcutaneous and fascial layers to the injured site (Fig. 1).
Several large hematomas were immediately encountered and removed. The paratenon
was carefully incised and tagged with 3-0 suture. As much of the tendon sheath as
possible was preserved. A large defect was identified at 3.5 cm. from the Achilles
insertion. Another defect was identified proximal to this location at -2.5 cm. (Fig. 2). The
necrotic and frayed ends of the Achilles tendon were excised to healthy tendon. This was
performed on both defects. The first defect measured 7 cm., and the smaller defect
measured 3 cm.
Attention was directed to the gastrocnemius aponeurosis at the myotendinous
junction, wherein a 7 cm. × 4 cm. graft was excised centrally (Fig. 3). An 8 cm. × 5 cm.
synthetic mesh was also cut and placed plantarly beneath the autogenous onlay graft. The
tendinous graft was sutured to the injured site using Kessler2 sutures and simple
interrupted sutures with 2-0 nonabsorable suture and 3-0 absorbable suture (Figs. 4 and
5). The mesh was also sutured in the same manner to both of the two ends of the ruptured
Achilles tendon, and the onlay graft, to augment the repair (Figs. 6 and 7). The second
rupture was repaired end to end using the Kessler technique. The tendon was dorsiflexed
maximally and measured ~15° beyond the perpendicular. The repair sites were strong and
taut.
The tendon sheath was reapproximated using 4-0 absorbable suture, as was the
subcutaneous closure using a running interlocking stitch. The skin was reapproximated
using 5-0 absorbable suture in a subcutaneous manner (Figs. 8 and 9). The wounds were
dressed in the usual sterile manner, and a posterior splint was applied with the foot at 90°.
No midthigh pneumatic cuff was used. There was an estimated 25 ml. of blood loss. The
patient tolerated the procedure well and was taken to the recovery room in stable
condition.

Postoperative Management

The patient was placed in a posterior splint for 3 days postoperatively. A

removable cast was applied after sterile dressings were changed, and his wound was
inspected. He was maintained nonweightbearing for 4 weeks, followed by a
weightbearing cast for another 3 weeks. He began physical therapy, which included toe
rises up to 100 single-leg toe rises twice per day, stationary bicycling, bicycling, walking,
and weight training to build up his Achilles tendon. A heel lift was used for 2 weeks after
the walking cast was discontinued.

Discussion

A very severe Achilles injury was described, as well as the challenging repair.
The mechanism of injury was fairly typical. The foot was planted, knee flexed, and the
Achilles tendon was stretched maximally when the injury occurred. The tendon was
ruptured in two separate locations. The repair required several modifications to
previously described and recommended procedures. An autogenous graft reinforced using
a synthetic mesh proved to be very strong in repairing the large defects. 2 The suture is
placed in the anterior portion of the proximal tendon, passed through to the distal portion,
and anterior, and the two ends of the suture are tied. The second stitch is placed in the
posterior proximal aspect of the tendon, and passed through to the distal posterior aspect
of the tendon, then tied on the side of the tendon posteriorly.

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Figure 1. A 25-cm. incision revealing a ruptured Achilles tendon.

Figure 2. Two sections of the Achilles tendon are ruptured proximal (measured to
be 3 cm.) and distal (7-cm. defect).

Figure 3. Excising the 7 cm. × 4 cm. autogenous graft from the aponeurosis.

Figure 4. The graft is measured to the defect distally.

Figure 5. The autogenous graft is sutured in place.

Figure 6. Synthetic mesh is sutured to the autogenous graft.

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The patient recovered and within 3 months was able to return to his activities, including
golf, volleyball, and walking.
He is now 14 months postoperative and has regained full strength and function.
He states that his left Achilles tendon is stronger than his right. The patient also states
that he can do the toe rise exercise easily and has no problems also performing single-leg
toe rises. He states that he is very happy with the surgical result. No complications were
noted.

Conclusions

A rare, but severe, acute Achilles tendon rupture is described and surgically
repaired using various modifications. The patient progressed expeditiously. He was able
to return to most of his sports activities after 3 months postoperative.

Figure 7. Repair completed for the distal rupture.

Figure 8. Subcuticular closure.

Figure 9. Preparation for dressings and posterior splint applications.

References

1. Kuwada, G. T. Classification of tendo Achilles rupture with consideration of

surgical repair techniques. J. Foot Surg. 29:361-365, 1990.
2. Kuwada, G. T. Critical analysis of tendo Achilles repair using Achilles tendon
rupture classification system and repair. J. Foot Ankle Surg. 32:611-616, 1993.
3. Arner, O., Lindholm, A. Subcutaneous rupture of the Achilles tendon: a study
of 92 cases. Acta Chir. Scand. 239:1-51, 1959.
4. Anderson, L. D. Affections of muscles, tendons, and tendon sheaths. In
Campbell's Operative Orthopaedics, vol. 2, pp. 1465-1469, edited by A. H. Crenshaw, C.
V. Mosby, St. Louis, 1971.
5. Kitting, R. W. Rupture of the Achilles tendon and related considerations. In
Reconstructive Surgery of the Foot and Leg, pp. 290-291 edited by E. D. McGlamry,
Intercontinental Medical Book Corporation, New York, 1974.

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