Exploring the Best Surgical Options for Achilles Tendon Repair

Avoid this mistake when undergoing Achilles Surgery!

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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 out—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 educate myself thoroughly on tendon healing and rehabilitation.

I read everything and anything related to Achilles' tears. My inner biomechanics and anatomy nerd, fueled by my passion to return to playing basketball, was relentless. 

As a result, I researched some fascinating findings in the physical rehabilitation world. I aspire to share this latest information with you to ensure you approach your surgery and recovery with confidence and determination.

What Are My Surgical Options?

First, let us look at one of the most critical aspects of your recovery: surgery. 

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 9 months to over a year, many patients can return to their activities as quickly as six months. 

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

In their cases, it's highly likely they underwent a similar procedure.  

• 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 can get to weight bearing and walking MUCH sooner than an open repair. This added benefit can't be overstated.

  • Several systematic reviews have proven that tendons respond tremendously to load, resistance, and graded exposure. The quicker you can perform isometrics, concentric strengthening, and walking, the less detrimental 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.
  

• However, studies indicate a higher re-rupture rate (3% to 10%) with percutaneous repair compared to open techniques. Additionally, there's a risk of sural nerve injury (3% to 18%), 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.

Summary

Open repair involves a larger incision and direct exposure of the Achilles tendon. At the same time, percutaneous surgery uses smaller incisions and specialized tools.

The most considerable drawback is the potential re-rupture rate and damage to the sural nerve.

However, researchers have proposed causes for immediate weight-bearing allowed without an orthosis, inadequate apposition of the tendon ends, and delayed repair.

The choice between them depends on the severity of the rupture, the surgeon's preference, and, most importantly, the patient's adherence to rehab precautions.

I do not hold any affiliations to 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