The goal of recovery is powerful function in the upper ankle joint (OSG). When properly indicated, conservative therapy (see “Other Therapy” below) can achieve an equally good result as surgical therapy.
Surgical therapy
Absolute indications
- Best possible functional recovery from complete rupture.
- Open rupture (tear)
- High demand of the patient (preferred in young athletic individuals).
Relative indications
- Partial rupture (tendon is partially torn).
- Re-rupture (renewed rupture)
- Rupture older than 4 weeks
- Under ultrasound control adaptation of the Achilles tendon at 20° plantar flexion (movement of the foot in the ankle joint towards the sole of the foot) not possible
- Failure of conservative therapy
- Patient request
Contraindications
- Poor general condition
- Poor skin and soft tissue conditions
- Multimorbid patients (patient with at least three diseases).
- Immunosuppression (suppression of the body’s own defense system).
- Systemic diseases (diseases that affect an entire organ system, such as the blood (leukemia, anemias), the central nervous system (CNS) or the muscles as a whole).
- Inactivity
The procedures
- Surgical refixation with postoperative immobilization sought; direct open sutures are replaced by minimally invasive procedures with percutaneous sutures (surgical treatment preferred in young, athletic individuals)
- Optimal operation time is in the first 48 hours after the event.
- If chronic ruptures and/or defect situations are present that do not lead to healing if left untreated, these are also treated by means of open sutures or minimally invasive techniques. The following reconstructive techniques are used:
- Turn-down flaps
- Free tendon transfer using flexor hallucis longus ((Latin for “long big toe flexor”; skeletal muscle and one of the toe flexors) or the hamstring (by “hamstring” we mean the ischiocrural (back of the thigh) musculature, which includes the following muscles: M. biceps femoris, M. semitendinosus and M. semimembranosus).
- Displacement plastics from the aponeurosis (dermal tendon plate (aponeurosis) on the planta pedis/sole of the foot).
Possible complications
- Open surgery (high rate of soft tissue complications):
- Wound healing disorders
- Hematomas (bruises)
- Infections
- Nerve injuries
- Movement restriction in the upper ankle joint (OSG)
- Reduction in strength
- Disturbance of the gait
- Rerupture (rupture again)
Other notes
- Open Achilles tendon suture leads to significantly more complications than conservative therapy.
- Patients in whom the ruptured Achilles tendon was sutured had more calf muscle strength than those treated conservatively (maximum plantar flexion over the first week; plaster removal after one week and replaced by orthosis). Athletically active patients benefited especially. Re-rupture occurred in 3% of operated and in 14% of non-operated patients.
- A minimally invasive or percutaneous procedure should be chosen for surgical therapy; percutaneous suturing significantly reduces the rate of wound infection.
Rehabilitation
- By early rehabilitation training (within two weeks postoperatively), consisting of ankle exercises with or without early weight bearing, good results can be expected.A three- to six-month break from sports must follow.
- Comparison of controlled early ankle weight-bearing (dorsiflexion of the foot against gravity; instruction: the patient sits on a table and dangles the feet, then moves the foot in the ankle joint toward the dorsum of the foot) from the third to the eighth week after Achilles tendon rupture with immobilization therapy (no weight-bearing until the 9th week) showed that early ankle weight-bearing alone did not harm patients. Week) showed that immobilization therapy alone did not harm patients: the Achilles Tendon Total Rupture Score (ATRS; max score 100) showed an average score of 74 in the early weight-bearing group and the immobilization group showed an average score of 75.
