Board Review Surgery

Current Technique for Surgical Repair of Ruptured Achilles Tendon

Michele Calderaro, MD

Michele Calderaro, MD presents multiple papers comparing conservative management and surgical repair of Achilles tendon rupture. Dr Calderaro also compares percutaneous vs open repair.

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Goals and Objectives
  1. Compare Conservative vs. surgical management of Achilles tendon rupture
  2. Compare percutaneous vs. open repair of Achilles tendon rupture
  3. Describe Dr. Calderaro's technique for Achilles tendon rupture
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  • CPME (Credits: 0.75)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.75 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Michele Calderaro, MD

    Orthopedic Surgeon
    Ospedale "San Pietro" Fatebenefratelli
    Rome, Italy

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    Michele Calderaro has nothing to disclose.

  • Lecture Transcript
  • Male Speaker: Program with a physician who’s come all the way from Rome, Dr. Michele Calderaro. He is the husband of Tara Giorgini. For many of you who remember, Rene Giorgini was one of our esteemed faculty for many years, and always in the educational light in New York. Tomorrow, we’re going to have a sponsored lecture in honor of Rene Giorgini and Tara is going to be giving that. But this morning, we’re lucky to have Dr. Calderaro come to us and speak to us on Achilles tendon ruptures. He graduated Medicine and Surgery from the University of Rome, specializes in Orthopedics and Traumatology. He has authored and co-authored numerous journal publications and is a speaker at national and international conferences. So, please welcome Dr. Michele Calderaro.


    Michele Calderaro: Okay. There, good. Good morning everybody. I think it’s this? I think it’s this? I think it’s this? Yes. Okay. My speech is going to be about Achilles tendon rupture. As all orthopedics and podiatrists, things could be treated conservative and surgical. Both the treatment have two goal. The first is approximate the tendon parts and the second one is to restore the tendon gland. If we achieve these two things, probably the treatment will be successful. We have to go through a little detail for literature that try to help us in understanding what is the best treatment we can give to our patient. You’re going to be, sooner or later, on the field and you’re going to have patients to treat by yourself, and you have to choose the choice that the best treatment is in your hand. This first paper basically should be the last one is the meta-analysis of randomized trials. Basically, it demonstrate that conservative treatment should be considered at center using functional rehabilitation, and surgical repair should be preferred at center that do not employ range of motion protocols. Basically, this is the end of my presentation, but I will go through other papers and other facts that probably help you as it helped me to take decision of how to treat patient with tendon rupture. The previous study was done in 2012. This is a study of a journal bone and joint surgery of 2010. Probably, it was one of the few studies because the study submitted on the previous study was almost 600 and only 10 study were considered to get their conclusion, the results. In the studies where was considered operative versus not operative treatment and conservative versus accelerated rehabilitation, and these studies conclude saying that accelerated functional rehabilitation and not operative treatment should be considered as best treatment. This other study is a systematic review, so it’s not a meta-analysis, always between surgical and not surgical. They were looking for complication. It say, basically, there was no significant difference on re-rupture, that is the most important complication of a surgery or a treatment. If you try to fix a tendon and it will re-rupture, that’s the worse thing can happen. There was also not like other big complication, but the patient satisfaction was major, was higher with surgical treatment.


    The end of the study say that rehabilitation basically was more important than treatment. It was focusing on the post-treatment than mostly on the treatment. So, it could be like more important for a physiotherapy congress than a surgery congress. In this other study, they proposed a new conservative dynamic treatment. Basically, they say that the results were good. But if you go to see the complication like re-rupture, basically there is like 7 over 57, so it was 14% of re-rupture. It looks like pretty high to me. The study concludes that this procedure is good enough as an alternative method to surgical treatment. I try to not give good enough treatment to my patient. I will try to give good treatment, not good enough. In this other study is compared surgical versus not surgical treatment and early versus late weightbearing. So, if we let the people walk early or late after surgery, basically they say that there are no statistical difference. But if you see the numbers, and that is about like re-rupture, there are 4% of eruption on surgical early weightbearing versus 12 and 6% late weightbearing on surgical versus 10. If I have to just watch number, I would say, “Okay, I do surgery on the patient with Achilles tendon and I will give them early weightbearing.” This other study is just a number study, and it just probably confuse you like they confuse me. In this other study, there was an evaluation of clinical and radiological facts of open versus percutaneous versus conservative. So, we see another word that is important, percutaneous. The surgery could be done open or percutaneous. Basically, the conclusion is there is no significant difference between the treatment of the three groups. It means, whatever you do is okay. The best thing is to do something. Okay? On this other paper compared percutaneous versus open. Also, this give similar results. The cosmetic appearance could be something that appeal the patient, especially if they are a woman, so there is a little point in favor of percutaneous. Just facts, these are an important study made by Leppilahti that is a Finnish guy. Basically, he’s the guy who made the scar system to evaluate how the results are in Achilles tendon. In Finland, they are big on Achilles tendon. Basically, they were comparing early weightbearing with early versus late mobilization in surgery. So, they do surgery and they were studying if early mobilization or late mobilization giving full weightbearing was better. In the study, basically the isokinetic strength and comparing in a long term [indecipherable] [09:20]. In fact, the big round is there are no long terms prospective controlled trials comparing post-operative regimen. In fact, if you look for papers on PubMed, there are not really good study. If you remember the first paper I showed you, over 600 paper, almost only 10 where the studies that were considered scientifically good enough to, in this case, use it, good enough to be considered as a scientific paper.


    Basically, he say that whatever you do, you’re going to have a good result because the patient satisfaction is good, but you’re going to have 90 to 95% of the recovery at one year like it is at 11 years. So, you get back the patient in a good way, but it will never recover it fully and completely, starting it with isokinetic and other stuff. After all this paper, I promise there are almost a few more. If I find a patient, a patient comes to me with a ruptured Achilles tendon, I try to give them the best treatment I can. The thing that I am more aware is the re-rupture and I ask to myself, “Why however you do the surgery, this tendon rupture?” And I start thinking that I think the most important thing is to find out where the tendon is lesion, how the tendon is lesion, and when the tendon is lesion. Where? Okay, there is a little [indecipherable] [11:19]. Okay. It’s missing one picture but it’s okay. The tendon could be lesion in the 3/4 of the cases at the midsubstance, so at the center of the tendon. Few cases are at the myotendinous junction, and about 1/5 to 1/4 would be considered avulsion, so in the last part of the tendon close to the insertion to the calcaneal. But this, I think, is the most important part, how the tendon breaks. We see different picture in our old tendon lesion, but how is the tendon is a lesion? Within the fiber of with continuity is this. If you will do or you have done open surgery of tendon, when you cut the skin, you will find different situation. This is like what I call within the continuity of the fiber. It looks like a pack of spaghetti that I’m used to treat, and the tendon is made of all fibers like a spaghetti. But if the fibers are broken, like far apart of them, if you pull out the two parts of the spaghetti, it looks like the pack is elongated but it still have continuity. That’s what happen if you pull up the tendon, it looks like it’s bent but it looks continuous. So, that’ how we call, within the fiber with continuity. The second one is this. Within the fiber without continuity, if you pull up that kind of lesion, you pull up and the fibers will torn apart, so there will a gap. Then, there will be the complete, the transverse with gap or without gap often is close to the calcaneal like an avulsion. That I think is the most important thing to consider on a tendon lesion. When the lesion is torn, it could be acute. Acute means that the tendon could be moving in one to four days due to the contraction of the gastrocnemius soleus complex or it could be neglected. One to 25% of the patient don’t know that they had Achilles tendon rupture. They think they had the sprain and they come to your office later on, and that’s a different thing. If you’re going to see this other study, and this paper is a systematic review and they also state that the conservative with early weightbearing is the best but associated in one study, with dynamic ultrasound assessment of the gap. You can do MRI, you can do whatever you want, but you can never find out how and when this tendon will have a gap.


    That I think is the key point of the re-rupture. If the two part of the tendons are not joined together in good tension, that tendon may lead to a re-rupture, and that is a big unsuccess for us. As I told you, I give you a lot of information and that happened to me too. Some words were going around my head, how is rupture that the gastro soleus will contract? Well, we will have a dynamic ultrasound. Who can do that? I can’t do that. Do I have always a functional rehabilitation? Do all my patient can go to a functional rehabilitation early and be followed very well? Is the result good enough for my patient? So, this is myself doing the lecture and say, “Oh Jesus, I don’t know what to do.” That is the answer I gave myself years ago. I always do surgery. So, I give you my answer, okay [laughs]? At this point, we have a double option. We do the surgery open or minor invasive. First, surgical treatment for open surgery is such suture or suture with enhancement. Of course, I do this in some specific case, but I’m always afraid of vast carrying of the surgical incision or bad complication that eventually is possible. If we consider athletes as like the Formula 1 is for the car, so lab to test extreme situation to bring back then to the normal life, we see how in this study, 31 athletes were treated and the return to sport occurred earlier, muscle atrophy was less and the functional score was better in this set of patient treated by percutaneous surgery. So, if it works in athletes, probably it works also in normal people, like it could be my patient, or me, or you. In this other paper, they evaluate chronic rupture Achilles tendon and they have good result. The conclusion is that we recommend this technique for treatment of chronic rupture of Achilles tendon. They use to perform Ma & Griffith technique. This is a kind of old paper, 2008. That’s all this consideration brought me to go towards many, in facility, about 10 years ago in doing rupture of Achilles tendon. At this point, we have different option. We have the percutaneous suture, where you basically suture the tendon without touching the area where the tendon is broken. That’s the Ma & Griffith technique. You have to cross through little stab incision, the tendon to cross the suture and joint. That leads you to a possible neural lesion. There are like other technique like the Tenolig that basically put some special anchors, but you’re never sure that the two parts of the tendon are connecting. In fact, that there are possible secondary rupture. There are minimal invasive. You just cut at the site of the lesion and you pass the wire and the suture through the tendon. And through the little incision, you can see the tendon, you can see if you have approximation of the two parts, and that’s what they do. You can go through different device, this Arthrex, this Achillon. You have the visual control of the suture and the tendon re-approximation, and you are sure with the percutaneous guide incision that you are in the tendon. The problem is that this device cost. In my public hospital in Italy, the DRG, the system of payment of the surgery is lower than the cost of this device. So, I come out in 2011 with a presentation at the Italian Congress with an alternative economical way to treat the percutaneous tendon repair, the lesion, with just a Vicryl 2 suture, ring forceps that usually help the obstetric and gynecologist.


    They use to grab the uterus with this. That is like a forcep with a ring at the end. It’s better if you have a long cannulated needle. That’s what they use in hip arthroscopy but you can find that as a device to take pieces of tissue, of ago-biopsy and some needle biopsy. So these are moving. I will repeat two times. The first time, it will go on. Can we start with the movie, please? Okay. No. Yes. There you go. Yes. Okay. So, you would find out where the tendon here is a lesion. This is the midsubstance, a little incision, 2, 3 centimeters. You find out the two parts of the tendon, you pull out. You see, that’s the two part. You grab both part of the tendon with a corker. You slide in through the paratenon, that ring forcep with the needle. You aim the two rings. You pull down the forcep and you are sure that you grab the needle. You take off the inside part and you pass the wire, okay? At this point, you remove the needle, the wire inside, you slide off the ring. If you correctly aim the ring, you will pull down that proximal part, you put the hand on the calf and you feel that the tendon is connected to the suture. And you do the same thing. Of course, this procedure is not good for proximal lesion too close to the tendon because you are not the tissue to put the suture through. As you see, it’s very simple. This is almost like live surgery and you are sure that you grab the tendon. You can feel it. You are sure. I used to pass three suture, but basically, now I pass two or one because my objective is only to approximate the two parts and give enough good tension to suture the tendon. It’s basically almost a conservative treatment through a little incision, but I want to be sure that the tendon, the two part are close together and that the tension is good. You see the Thompson maneuver at the end of the surgery is good. So, if I don’t find these, I will open the tendon 3 centimeters and it’s good. I put anterior splint, so I can check the back part. I’m not like very much to the early weightbearing, but I give some time to recover, like about two weeks, and then I let the people walk with a CAM walker. I put, again, the video because probably this is the most important thing after all the paper. A little incision, 2 centimeter, I find out the tendon. This is probably a lesion without continuity, because as soon as you pull out, you see there is a gap. You slide through under the skin, in the fascia, the ring. I try always to go higher as possible. You see, I pull down the forcep and the needle moves, so I’m sure I’m inside the thing. I took off the inside of the needle, I slip in the suture. Remove the needle and slid off the forceps. If you are good enough to figure out where the places of the ring, it just never miss the thing. The important is to not try to stab the skin too many times, because you will see, I had like little complication but mostly my colleague. Because when I start doing this technique, a colleague of mine start using too. When you are not very, very good on hit the ring at the beginning, you start stabbing the skin and it could be some complication. Then, the first suture, you give the knots, close it and then you give the other one. So, with the other one, you give the tension of the tendon as much as you want. You give a little slight dorsiflexion of the foot, so you re-approximated the two part on the tendon. After you give the first knot, you give the second one.


    One is blocked, that will close the tendon together, okay? Can we go on? Okay. This is I consider an extreme case that I like to present, because this is a 72-year-old patient that come to me eight days of post trauma. He thought he had like an ankle sprain. They taped it and this is how it came to me. Of course, it could be a candidate for a non-surgical treatment, I wouldn’t mistake, but he had vasculopathy so I didn’t want to risk some embolism or whatever. I wouldn’t do an operate procedure on this because you see how the skin is. So, I decide to do a percutaneous, like I do in 95% of my cases. Find the stomp and did a good re-approximation through a 3-centimeter cut. This is what happened. Please, the video. You see on the left, the little incision. Can we start with the video, please? Can we start with the video? This is two months after surgery. Seventy two years old, you can the skin burns of the taping and that’s how it get to my office after a little bit more than 60 days. He could stand on his toe and he almost could walk. He’s 72, I remember, on his toes. You see, the skin is still like burn, so it’s kind of fresh and that’s the results that I consider excellent in almost extreme case, isn’t it? Of course, I didn’t see him anymore. This is the paper I presented at that time in 2011. I had no complication, the first 20 conservative patient with clean improvement in three to four months, and we had, say we because this technique was performed by other colleague of mine. We had one infection on a diabetic patient, one sural nerve entrapment. I think this situation occurred, the first one, probably because we stabbed too many times in through the skin. The second one, because we didn’t have too many needles, and so the needle was not sharp enough to not be too much invasive and aggressive, I think maybe. We always have to think why the things don’t go well and try to find an explanation. Whatever you’re going to do when you’re going to be on practice, my advice is approximate the tendon parts and restore the tendon leg however you do. I want to thank you that I could finish this presentation without any major lesion for myself. [Laughs]. English is not my language.