In the context of conservative therapy of the Achilles tendon rupture, reference has already been made to the ultrasound examination and the possibility of conservative therapy in the specific case. However, if the ultrasound examination of the Achilles tendon rupture reveals that the two ends of the tendon are far apart, it is clear that the ends of the tendon can no longer grow together on their own. An operation of the Achilles tendon rupture must be initiated.
During the operation, the skin above the Achilles tendon is cut open. This requires a few centimetres of incision (the length can vary). Torn and dead tendon parts are removed and the ends of the tendon are sewn together again.
Sometimes a suture through the bone (transosseous) is necessary. After surgery for the Achilles tendon tear, the leg is immobilized in a 30° to 40° pointed foot position to relieve the suture with the aid of a lower leg walking cast. The patient may then only partially load the leg.
After about two weeks, the stitches are removed and a new plaster cast is applied. As a rule, the degree of the pointed foot position is reduced (pointed foot position about 10° to 20°). Even now, the leg may only be partially loaded for a further fourteen days.
Afterwards the cast is removed again and after checking the healing process another lower leg walking cast is made. As a rule, it is now possible to dispense with another pointed foot position. The patient may then – provided he or she is pain-free – put full weight on the leg again.
The plaster is removed a further fourteen days after the operation. After initially partial weight-bearing, the load is gradually increased until the patient is able to bear the full load. This increase in load and especially the joint mobilisation should be carried out and trained in the subsequent rehabilitation measure (exercise therapy).
In a scientific comparison of the forms of therapy, a higher healing rate is attributed to the surgical therapy. However, it should never be forgotten that this is an operation and that the risk of wound infection always plays a role. Newer surgical techniques can in some cases significantly reduce the risk of infection (see Prognosis). Recent studies show in part that, especially in older patients, good results can be achieved without surgery for tendon ends that are not far away.
After a rupture of the Achilles tendon has occurred, therapy should be initiated relatively quickly. Once the decision has been made to operate on the tendon, this usually takes place within a week, since if the waiting time is too long, the calf muscles shorten and the prognosis is postponed unfavourably. As long as surgery is performed within the first 24 hours, the physician speaks of a “fresh” Achilles tendon rupture: The calf muscles have not yet shortened and the tendon ends are not stiffened.
The duration of the operation depends on the individual findings, but also on the surgical technique used. In general, there are two surgical techniques that can be used in the case of an Achilles tendon rupture. The classic, open surgery, which is performed as standard, usually takes about one hour.
In the open Achilles tendon operation, an approximately 10 cm long skin incision is made in the heel. After removing the damaged and torn tendon parts, the surgeon sutures the two ends together again (“end-to-end suture”). He uses a self-dissolving thread for this purpose.
More modern, but also not suitable for all injuries, is the percutaneous or minimally invasive technique. Only through a single, approximately 2 cm. long incision above the tendon tear, the sutures are placed under ultrasound control with a special instrument. If you decide on a minimally invasive procedure, you can expect a comparatively short operation time. The open procedure, on the other hand, requires more time.