Exploring the Best Surgical Options for Achilles Tendon Repair

Which surgery technique is most effective? Does it matter, and which should you opt for?

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If you're reading this, you're probably on the receiving end of some unfortunate news.

You need surgery, and the idea sounds daunting.

Even though the process can make you want to pluck your own eyelashes —I mean, there's only so much Netflix and video games you can binge—I promise it is not as intimidating as it may initially seem. 

As someone who ruptured their own Achilles in 2019 (while playing pick-up basketball, ouch!) and is a board-certified licensed physical therapist, I used this experience to read anything I could get my hands on. Thanks, Covid.

My inner biomechanics and anatomy nerd, fueled by my passion to return to playing basketball, was relentless. 

As a result, I came across some interesting findings in the research field. There is no black-and-white answer, but the following information should help inform your decision and conversation with your surgeon.

What Are My Surgical Options?

Achilles rupture repair can be done using two main methods: open repair and percutaneous surgery.

I'll break them down more below:

Procedure:

• Open Repair: In open repair, a surgeon makes a larger incision in the skin to access the damaged Achilles tendon directly. The torn ends of the tendon are then stitched together.
  

• Percutaneous Surgery: In percutaneous surgery, smaller incisions are made, and specialized instruments are used to repair the Achilles tendon without directly exposing it.
  

Here is a short video that visually demonstrates the difference.

Incision Size:

• Open Repair: Requires a larger incision, which may lead to a more noticeable scar, increased scar tissue, and more swelling.
  

• Percutaneous Surgery: Involves smaller incisions, reducing the potential for visible scarring.
  

Infection Risk:

• Open Repair: Due to the larger incision, there is a slightly higher risk of infection.
  

• Percutaneous Surgery: Smaller incisions generally result in a lower risk of infection.

Recovery Time: 

This is the most significant advantage of percutaneous surgery. Instead of rehab protocol taking anywhere from a year or more, some elite athletes can return to their sport-related activities as quickly as nine months.

For NFL, NBA, and Futbol fans, you've probably read news of athletes like Cam Akers, Kevin Durant, or even David Beckham making a ridiculously fast return to professional sports after an Achilles rupture.

After discovering that a newer procedure known as the SpeedBridge technique is becoming more popular, I updated this blog post. This method was performed by Dr. Neal ElAttrache, and his patients returned to sports in an impressive six months! For this blog post, I'll concentrate on the most widely used procedures. Remember, 99.9% of us don't possess the genetic advantages of NFL athletes, so for now, temper your expectations.

Still, percutaneous repair has been linked to a quicker return to work/participation rate, which, depending on your particular situation, could mean the difference between being able to close an important deal and earn for your family or losing out on a promotion.

• Open Repair: Recovery may take longer because of the larger incision and potential impact on surrounding tissues. There's more inflammation in the heel and lower leg, which requires delayed healing times and more time in a walking boot. 
  

• Percutaneous Surgery: Generally has a shorter recovery time as it is less invasive. This means you might tolerate early weight bearing and return to walking at a faster rate.

  
  

  • Several systematic reviews have proven that tendons respond tremendously to load, resistance, and graded exposure. The quicker you can perform progressive strengthening exercises, the less detrimental the effects and atrophy you will face. 
    

Complications:

• Open Repair: May have a higher risk of complications, like wound healing problems. The rate of re-rupture of the Achilles tendon after surgical treatment has been reported to be in the order of 1.7%–5.6%
  

• Percutaneous Achilles tendon repair is often linked to high satisfaction and fewer complications compared to open procedures. People who undergo percutaneous repair usually have less noticeable scars because the repaired tendons are thinner.
  

• Studies indicate a similar re-rupture rate (1%-6%) with percutaneous repair compared to open techniques. Additionally, there's a risk of sural nerve injury (3% to 6%), leading to persistent sensations and, in some cases, requiring further surgery.

  
  

Suitability:

• Open Repair: Often preferred for complex cases or when the surgeon needs a clearer view of the tendon.
  

• Percutaneous Surgery: Suitable for less severe cases and when minimizing scarring and recovery time is a priority.

  
  

Anesthesia:

• Open Repair: Typically requires general anesthesia.
  

• Percutaneous Surgery: This may be performed under local or regional anesthesia.

  
  

Which Option is Better?

Cross Comparison of Open Repair vs Percutaneous Surgery

The answer? It depends.

Those who are at high risk for wound infections (typically older than 60, obese, diabetic, or inactive) might be better suited for a percutaneous repair.

OR

They might even be better off going the conservative route instead.

Meanwhile, if you're young, in shape, and relatively active, you will likely have an easier time recovering and want to minimize your risk of a potential nerve injury as much as possible. In this case, an open repair might be better.

Some surgeons and physios still believe that putting weight on the foot too soon (especially without a boot) can lead to improper healing or increase your risk of re-rupture. I can understand this mindset because in physical therapy school, they hone in on one value above everything else, and that is to "do no harm".

However, the research strongly suggests otherwise.

The Importance of Early Loading

This research looked at 20 high-quality studies (called randomized controlled trials) involving over 1,000 patients who had surgery for a torn Achilles tendon. The researchers wanted to find out:

• How safe different rehab methods are

• How often people had complications or re-ruptures

• How quickly people returned to work or sports

• Whether faster, more active recovery programs work better than the traditional, more cautious ones

  
  

They divided all the rehab methods into 4 groups, based on:

• Whether the person was allowed to put weight on the leg early (Weightbearing = WB) or not (Non-weightbearing = NWB)

• Whether the ankle was moved early (Mobilization = M) or kept immobilized (IM)

  
  

Group 1 (WB + M) – Weightbearing and ankle movement early

Group 2 (WB + IM) – Weightbearing but no ankle movement early

Group 3 (NWB + M) – No weightbearing but ankle movement allowed

Group 4 (NWB + IM) – No weightbearing and no ankle movement early

The researchers discovered that overall, re-rupture rates were very low (only 2.7%). Group 1 (WB + M) experienced the lowest re-rupture rate. Group 1 resumed work and sports earlier than the other groups. All groups showed improvement over time. While no significant differences were observed at 1 year.

Modern research supports initiating weight bearing and mobility sooner is safe, reduces the risk of complications, and facilitates a quicker return to normal life.

The surgical technique depends on the location of the tear, what the surgeon prefers, your prior and current health, and, most importantly, how well the patient can follow the rehab rules and protect their healing tendon.

If you're looking for personalized guidance on your Achilles tendon injury, I’m here to help. Contact me to schedule a consultation call or email, and I'll create a plan tailored to your unique needs and goals.

I'm currently accepting new clients, so reach out today to get started on your path to healing.

Disclaimer

The information provided in this blog is strictly for educational and informational purposes. As a doctor of physical therapy, I aim to share the latest knowledge and insights about injuries, conditions, and rehabilitation. It is essential to understand that every individual's health condition is unique, and the content presented here should not replace professional medical advice or personalized care.

A qualified healthcare provider or licensed clinician can perform a thorough physical evaluation and conduct examinations while taking an extensive history to guide you through making an informed decision. The author of this blog post and its published platform shall not be held liable for any consequences, injuries, or damages resulting from using the information provided.

I do not hold any affiliations with any medical associations or universities mentioned in this article.

References

Henríquez, H., Muñoz, R., Carcuro, G., & Bastías, C. (2012). Is Percutaneous Repair Better Than Open Repair in Acute Achilles Tendon Rupture? Clinical Orthopaedics and Related Research, 470(4), 998-1003. https://doi.org/10.1007/s11999-011-1830-1

Bohm, S., Mersmann, F., & Arampatzis, A. (2015). Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports medicine - open, 1(1), 7. https://doi.org/10.1186/s40798-015-0009-9

Massen, Felix Kurt, et al. "Rehabilitation Following Operative Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis." EFORT Open Reviews, vol. 7, no. 10, 2022, pp. 680–691. https://doi.org/10.1530/EOR-22-0072.