FOOT & ANKLE INTERNATIONAL

Copyright 2012 by the American Orthopaedic Foot & Ankle Society

DOI: 10.3113/FAI.2012.0848

Primary Achilles Tendon Repair with Mini-Dorsolateral Incision Technique

and Accelerated Rehabilitation
Scott A. Hrnack, MD1 ; John M. Crates, MD2 ; F. Alan Barber, MD, FACS2
Plano, TX

ABSTRACT

Level of Evidence: IV, Retrospective Case Series

Background: No consensus exists for the best primary repair of

acute Achilles tendon ruptures. Problems with wound healing
and nerve damage can occur. Prolonged immobilization leads
to stiffness and calf atrophy. This study assesses the clinical outcome of acute Achilles tendon repairs using a minidorsolateral incision followed by a rapid rehabilitation program.
Materials: A consecutive series of acute Achilles tendon ruptures
repaired using a mini-dorsolateral incision were reviewed with a
minimum 12 months follow up. Fifteen patients with an average
age of 44 (range, 32 to 60) years were followed an average of
45 (range, 14 to 72) months. Two modified, buried core high
strength sutures were placed in each torn end of the Achilles
tendon reinforced with a running circumferential whip-stitch.
Ankle Hindfoot scores, single toe raises, calf circumference,
and adverse events were recorded. An accelerated postoperative rehabilitation protocol was followed. Results: Postoperative
AOFAS Ankle Hindfoot scores averaged 98.3 [39 pain; 49.6
function; 9.3 alignment]. All patients could single heel raise.
Eight of 15 demonstrated atrophy with an average calf circumference loss of 1.0 cm. The only postoperative complication was
one case of superficial cellulitis successfully treated with oral
antibiotics. There were no sural nerve injuries, wound break
down, or re-ruptures at final followup. Conclusion: The repair
of acute Achilles tendon ruptures through a minimal lateral
incision provided excellent functional outcomes, avoided complications including sural nerve injury, and allowed a return to
sports between 4 to 6 months.

Key Words: Achilles Tendon Rupture; Mini-Dorsolateral Incision; Accelerated Rehabilitation; Ankle; Surgical Repair

1
2

INTRODUCTION

Achilles tendon ruptures are a common injury. Nonoperative and operative approaches are viable options.
Despite the extensive literature concerning Achilles tendon
ruptures, there is no consensus on a surgical procedure for
the primary repair of acute Achilles tendon ruptures.2,3,6,8,11
Ultimately, the goal is to restore function to preinjury levels
and avoid complications. Open surgical techniques have been
associated with wound healing problems, and both open and
percutaneous surgical methods have the potential for nerve
damage.
The rehabilitation after surgery impacts the clinical
outcome and ease of recovery.4,5,12 14 Immobilization of the
repair may help to protect the repair and allow the disrupted
collagen to heal. It also leads to ankle stiffness and calf
atrophy. Recent literature has shown improved results with
early mobilization after Achilles repair.5,6,12 A standard rehabilitation program usually restricts weightbearing during the
first 6 weeks, allows biking and jogging at 12 weeks, and
a full return to sports at 6 months. A more accelerated
rehabilitation program would have many advantages. The
hypothesis of this study was that a mini-dorsolateral approach
for repairing an acute Achilles tendon rupture would provide
excellent surgical results without major surgical complications and permit an accelerated postoperative rehabilitation.
The purpose of this study was to assess the clinical outcome
of acute Achilles tendon repairs using a mini-dorsolateral
incision followed by a rapid rehabilitation program.

Action Orthopaedics and Sports Medicine, Decatur, TX.

Plano Orthopedic Sports Medicine and Spine Center, Plano, TX.

No benefits in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
Corresponding Author:
F. Alan Barber, MD, FACS
Plano Orthopedic Sports Medicine and Spine Center
Sports Medicine
5228 West Plano Parkway
Plano, TX 75093

MATERIALS AND METHODS

Starting in 2005, patients sustaining an acute subcutaneous Achilles tendon rupture were repaired using a

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Foot & Ankle International/Vol. 33, No. 10/October 2012

mini-dorsolateral incision. These patients were prospectively

followed to evaluate their outcomes. Ruptures were diagnosed by physical examination including a palpable defect
in the tendon and a positive Thompsons squeeze test. Ankle
radiographs were obtained in all cases. Functional outcomes
measured by AOFAS Ankle Hindfoot scores7 and single
heel raises. The average calf circumference difference was
measured using a tape measure 4 cm below the tibial tubercle
and compared to the unaffected side. Any adverse events
were recorded. Patients were reevaluated at 12-month intervals. The integrity of the Achilles tendon was assessed by
physical examination for tenderness, a palpable defect, or
positive Thompsons test.
Fifteen consecutive patients, 14 men and one female, with
an acute subcutaneous rupture of the Achilles tendon were
followed for an average of 45 (range, 14 to 72) months. The
average age of these patients was 44 (range, 32 to 60) years.
Eight ruptures involved the left leg and seven involved the
right leg.
Inclusion criteria were patients from 20 to 65 years old
with a first-time acute subcutaneous Achilles tendon rupture
(presenting within 14 days of injury), closed injury, the
completion of an accelerated postoperative rehabilitation
protocol, and a minimum followup of 12 months. Exclusion
criteria were diabetes mellitus, rheumatoid arthritis, autoimmune disorders, previous corticosteroid injections near the
Achilles, insertional, or musculotendinous ruptures sites or
prior tendon ruptures at the ankle.

ACHILLES TENDON REPAIR

849

Fig. 1: Incision centered on palpable defect on dorsolateral aspect of

Achilles tendon.

Surgical technique

Once properly anesthetized and in the prone position, a

clinical exam was performed to confirm the preoperative
clinical diagnosis by palpating the defect in the Achilles
tendon and performing a Thompson test. A calf tourniquet
was placed at the proximal to mid portion of the muscle
belly in every case but not inflated and the lower extremity
prepped. A 2.5- to 5.0-cm incision was centered at the
area of palpable defect on the dorsolateral aspect of the
Achilles tendon (Figure 1). Once the incision was made,
blunt dissection was used to identify the sural nerve and
the lesser saphenous vein in the lateral edge of the wound
(Figure 2) which were gently retracted laterally.
Minimal debridement of the tendon was performed
excising only scarred, pseudotendinous material. Using a
No. 2 ultra-high-molecular-weight-polyethylene (UHMWPE)
suture a modified Kessler core tendon stitch was placed in
the proximal tendon leaving two strands for subsequent tying
(Figure 3). Using another No. 2 UHMWPE suture, a similar
modified Kessler stitch was placed in the distal tendon. Traction was placed on both suture strands to ensure good incorporation of the suture into the tendon and the tendon was
then tied (Figure 4). After both sets of sutures were tied an
absorbable suture (No. 0 Vicryl, Ethicon, Somerville, NJ) in a
running locking whip-stitch reinforced the repair (Figure 5).

Fig. 2: After subcutaneous dissection, the sural nerve and lesser saphenous
vein are identified and protected.

The peritenon and skin were closed and a short-leg

fiberglass cast was applied to the leg in mild plantarflexion.
Postoperative management

All patients completed an accelerated postoperative rehabilitation protocol. Seven days postoperatively, the cast
applied at the time of surgery was removed and the wound
checked. Sutures were removed between 1 to 2 weeks based
upon wound healing. After cast removal, patients were placed
in a walking boot with a 6-cm heel lift and allowed to begin
ambulation. Passive range of motion in all planes except
dorsiflexion was allowed.

Copyright 2012 by the American Orthopaedic Foot & Ankle Society

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HRNACK ET AL.

Foot & Ankle International/Vol. 33, No. 10/October 2012

began concentric/eccentric training with assistive devices

(sportcord, bungee). After 4 months, patients were allowed to
begin sport specific activities and running. Discharge criteria
included the ability to perform a single leg raise and no
greater than 1 cm gastrocnemius size difference.
RESULTS

Fig. 3: The proximal end of the ruptured Achilles tendon is identified and
a modified core suture is placed in the proximal stump.

Postoperative AOFAS Ankle Hindfoot scores at final

followup averaged 98.3 (39 pain, 49.6 function, 9.3 alignment). All patients were able to do single heel raises.
However, 8 of the 15 patients had measurable calf atrophy.
The average calf circumference difference was 1.0 cm
compared to the unaffected side.
The only adverse event was one case of superficial
cellulitis treated successfully with oral antibiotics.
DISCUSSION

Fig. 4: Both proximal and distal Achilles stumps are approximated by the
two core sutures.

Fig. 5: A running locking circumferential whipstitch completes the repair.

At 6 weeks, patients removed the boot and began active

range of motion in all planes. Gentle Achilles tendon
stretching and calf raises were started. At 10 weeks, walking
on an inclined treadmill was started. At 12 weeks, the patients

Acute Achilles tendon ruptures are a common orthopedic injury. Khan et al. determined in a meta-analysis
that open operative treatment of acute Achilles tendon
ruptures decreased the rerupture rate when compared to
nonoperative treatment.6 However, operative treatment was
associated with a significantly higher rate of major complications including wound breakdown, adhesions, infection, and
neurovascular damage. This meta-analysis concluded that
these major complications can be reduced by performing the
surgery percutaneously.6
The current report describes a limited mini-open, dorsolateral approach to the Achilles tendon for primary surgical
repair. There are several advantages to this approach. The
sural nerve crosses the lateral border of the Achilles tendon
between 9 to 12 cm proximal to the insertion of the
Achilles.1,15 The majority of Achilles ruptures are at the mid
portion of the tendon, which is well away from this location.
Webb et al. stated that the course of the sural nerve is highly
variable and this variability could lead to a higher incidence
of sural nerve injury for percutaneous repairs.15 By using a
limited incision over the lateral aspect of the tendon, the sural
nerve, as well as the lesser saphenous vein, can be identified
visually and protected.
A smaller incision greatly reduces the amount of dissection, minimizing the extent of Achilles tendon devascularization. Furthermore, acutely addressing the injury minimizes
the amount of pseudo-tendinous material present. A smaller
incision, while allowing for adequate visualization of the
tendon, limits the potential for wound breakdown and infection which has been shown to result in poor clinical
outcomes.9 Repairing the peritenon also helps protect the
vascular supply of the tendon which aids with healing.
Rehabilitation protocols have an effect on Achilles tendon
healing and the clinical outcome. Multiple studies have
shown the benefit of early mobilization after surgical

Copyright 2012 by the American Orthopaedic Foot & Ankle Society

Foot & Ankle International/Vol. 33, No. 10/October 2012

repair5,6,12 as well as weightbearing.13,14 These benefits include less Achilles tendon elongation and improved
outcomes scores with early motion.10 The rehabilitation
protocol used in the current patient group included earlier
cast removal (at 7 days) than customarily recommended
followed by weightbearing in an orthosis. This accelerated
program was thought possible because of the increased repair
strength provided by the incorporation of UHMWPE repair
sutures reinforced by a circumferential whipstitch. The lack
of rerupture supports this contention.
This study has limitations including the small study group
size and the lack of a control group. Strengths of the study
include a single surgeon (JMC) and the 45-month average
followup.
CONCLUSION

ACHILLES TENDON REPAIR

4.

5.

6.

7.

8.

9.

The repair of acute Achilles tendon ruptures through

a minimal lateral incision yielded excellent functional
outcomes, avoided complications including sural nerve
injury, and permitted a return to sports between 4 to 6 months
after surgery.
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Copyright 2012 by the American Orthopaedic Foot & Ankle Society