AANA Lab Course 908-Foot and Ankle Arthroscopy (APEx)-Open Repair_ Still the Gold Standard-Richard Ferkel, M.D.

Open Repair_ Still the Gold Standard-Richard Ferkel, M.D.

Pdf Summary

The Achilles tendon is the largest tendon in the body, connecting the calf muscles (gastrocnemius and soleus) to the heel bone, with a complex anatomy that includes a spiral twist providing elasticity but also a vulnerable “watershed” zone 2-6 cm above its insertion. Achilles tendon ruptures, which commonly occur in active adults aged 30-50 and “weekend warriors,” have increased in incidence over the past 50 years, mostly at this watershed area. Acute ruptures present with pain, swelling, difficulty walking, and a palpable gap, often diagnosed clinically without requiring MRI except in large patients.<br /><br />Open Achilles tendon repair remains the gold standard surgical treatment, especially for acute complete ruptures. The procedure involves a medial incision to avoid injuring the sural nerve, careful handling to preserve skin and paratenon, debridement, and secure tendon repair using strong nonabsorbable sutures with Krackow locking stitches to reestablish physiologic tension by comparing with the uninjured side. Plantaris tendon reinforcement may be used if available. Postoperative management includes casting or early motion protocols depending on repair quality, with early functional rehabilitation improving outcomes and return to near preinjury function by six months.<br /><br />Complications of open repair include infection, adhesions, nerve injury, wound issues, and rerupture, though rerupture rates are lower than with nonoperative management. Surgery shows faster and better recovery of muscle strength and function compared to nonsurgical treatment.<br /><br />In professional athletes, especially NBA and NFL players, Achilles rupture repair outcomes are mixed: return to play rates range around 60-70%, with many players experiencing reduced playing time, performance, and shorter careers post-injury. Younger age and lower BMI predict better outcomes. Despite these challenges, open Achilles repair remains favored for restoring function and allowing early rehabilitation.<br /><br />In summary, open Achilles tendon repair offers excellent tendon apposition, tension restoration, paratenon preservation, nerve protection, and enables early motion, making it the preferred treatment choice for acute Achilles ruptures, including athletes seeking high-level recovery.

Keywords

Achilles tendon

tendon rupture

open Achilles repair

watershed zone

Krackow suture

plantaris tendon reinforcement

postoperative rehabilitation

complications

return to play

professional athletes