1. Intermediate Format: Tenorrhaphy Achilles Tendon Repair
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Procedures
Intermediate Format:
Tenorrhaphy
Achilles Tendon Repair
Picture from An Atlas of Human Anatomy by Carl Toldt, M.D., 1919.
See MAVCC Unit 10, OBJ 21 for general statemesnts to understand about Tendon Repair
Overview & Description Allrefer.com
Tendon repair can be performed a using local anesthesia (the immediate area of the surgery is pain-free), regional anesthesia (the local area and surrounding regions nearby the surgical area are pain-free) or general anesthesia (the patient is unconscious and the area is pain-free). An incision is made over the injured tendon. The damaged or torn ends of the tendon are sewn together.
If the tendon has been injured severely, a tendon graft may be required (a piece of tendon from the foot or toe or another part of the body is often used). If necessary, tendons are reattached to the surrounding connective tissue. The area is examined for injuries to nerves and blood vessels, and the incision is closed.
Wheeless:
Operative Repair: - discussion: - most indicated in a younger patient w/ a clinically displaced rupture; - may allow earlier return to sports, earlier return of muscle power, and a lower re-rupture rate as compared to non operative treatment; - main complication is wound slough;

2. Objectives
Assess the related terminology and pathophysiology of the tenorrhaphy_.
Analyze the diagnostic interventions for a patient undergoing a tenorrhaphy.
Plan the intraoperative course for a patient undergoing tenorrhaphy.
Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives Choose the appropriate patient position
Identify the incision used for the procedure
Analyze the procedural steps for tenorrhaphy.
Describe the care of the specimen

4. Terms and Definitions Tendon Paratenon Equinus
Long, tough strands of fibers that form ends of muscles. Tendons connect muscles to their bony origins and insertions
Paratenon
Fatty and areolar tissue that fills the spaces withing the facscia around a tendon
Equinus
Tightness (loss of flexibility) in calf and Achilles Tendon (results in “toe-walking”
MAVCC OBJ 1

5. Definition/Purpose of Procedure
The goal of tendon repair is restoration of normal function of joints or surrounding tissues following a tendon laceration
The goal of tendon repair is restoration of normal function of joints or surrounding tissues following a tendon laceration
To repair a torn tendon and to restore normal function to the joints and tissue surrounding the tendon
Surgical repair of a damaged or torn tendon

6. Pathophysiology From nucleusinc.com Extensor tendon (thumb)
Repair of Tendons in the Left Shoulder
                                                                                                             
Depends on the location of the injured tendon; may be the hand, foot, ankle, wrist, shoulder, hip, knee, and elbow
Extensor tendon (thumb)
Achilles tendon (calcaneous)
Patella tendon (knee)
The Achilles tendon, connecting the calf muscles to the heel, is one of the strongest tissues in the body. Injury to this dense band of tissue most commonly occurs in the 30 to 60 year old males while playing tennis or basketball. The patient usually reports feeling a "shot" in the back of the calf and then having sharp pain. Swelling usually occurs from the bleeding associated with the tendon rupture. (stoneclinic) So– it is most often
DX is made by H & P. The rupture can be confirmed with a positive Thompson test: the examiner squeezes the calf while the patient lies on his stomach—normally causing the foot to point like a ballerina. When the Achilles Tendon is completely torn, the foot does not point because the tendon connecting the large muscles of the calf to the heel bone is ruptured. Usually the defect in the ruptured tendon can be felt by the examiner as well. An office based MRI shows the type and area of the tear.
From nucleusinc.com

7. Surgical Intervention: Special Considerations
Patient Factors
Surgical time frame: considered an emergency—must be performed asap before tendon atrophies
Room Set-up
Prep: from mid-thigh to toes and draped w/extremity drape.
For an achilles tendon repair on a n athletic person, a percutaneous suture technique may be used.

8. Surgical Intervention: Positioning
Position during procedure
Depends on site of injury
Achilles Tendon: Prone ; if surgical assistant not available, position so that dorsum of forefoot remains on the table (not dangling) so that foot can be held in equinus during the tendon repair
Supplies and equipment
Esmark and Tourniquet upper thigh
Special considerations: high risk areas—chest rolls and padding for bony prominences, proper head alignment
Wheeless:
positioning: - place the tourniquet on the leg in the supine position, before turning the patient prone (its difficult to place the tourniquet in the prone position); - before prepping, note the resting equinus position of the uninjured leg (and attempt to reproduce this equinus position during surgery); - if a surgical assistant is not available, position the patient so that the dorsum of the forefoot remains on the table (not dangling off the table), so that the foot can be held in equinus during the tendon repair;

9. Surgical Intervention: Special Considerations/Incision
When tendon is still of full length, the torn ends are sutured together
If ruptured near calcaneous, will need to reinsert the proximal end of the tendon into the bone
State/Describe incision
longitudinal incision is made just medial to achilles tendon
Local, regional, or general anesthesia, depending on where the tendon is located
incision: - longitudinal incision is made just medial to achilles tendon; - a medially placed incision may be less likely to slough from the pressure that the repaired tendon exerts on the overlying skin; - additionally a medially placed incision is less likely to develop postop adhesions; - a laterally placed incision may injure the sural nerve and the lesser saphenous venous plexus;

10. Surgical Intervention: Supplies
General
Specific
Suture: strong polyester braided suture
Medications on field (name & purpose)
Catheters & Drains
Cast material: Orthoglass Splint 6” x 15”
For Tendon Repair: # 1 Tevdek or # 5 Ethibond (Hold)—a strong polyester braided suture material (Deknatel turned to Genzyme) Other hold items: # 2 Mersilene, O Ethibond. Also: 2-0 Vicryl , 3-0 Vicryl, 2-0 Prolene

11. Surgical Intervention: Instruments
General
Basic ortho set
Specific
Miltex tendon-pulling forceps (Fig 21-28)—flexible or rigid
See p. 841 STST Fig Used to grasp the proximal portion of the tendon to bring into place for the repair

12. Surgical Intervention: Equipment
General: Hand, Foot, Shoulder set—depends on location of tendon laceration or rupture; Tourniquet w/supplies (place before pt is turned prone)
Specific

13. Surgical Intervention: Procedure Steps
Incision, Hemostasis, Retract
Irrigate, Hemostasis, Close Wound in Layers
Tenorrhaphy: An incision is made over the injured tendon. The torn ends of the tendon are located and sewn together. In cases of severe injury, a tendon graft may be required. In this case, a piece of healthy tendon is taken from another part of the body, often from the foot or toe, and is used to reconnect the broken tendon. And in some cases, the tendon may need to be reattached to surrounding connective tissue.
The area is examined for injuries to nerves and blood vessels, and the incision is closed with stitches, which are usually removed about 10 days after surgery. The doctor may put you in a splint or plaster cast to keep the injured area in position for proper healing. This will stay on for 2–6 weeks after surgery.
Achilles Tendon Summary: anesthetize the area with local anesthetic and sedate the patient with IV meds. The proximal portion of the tendon, as ID’d by palpation and MRI, is then captured wit # 1 Tevdek (braided polyester) suture placed transversely thru the skin and the tendon and out the opposite side. This suture is then crisscrossed thru the tendon, the gap at the rupture site, and then thru the distal portion of the tendon just above the calcaneous (heel bone), thru the skin punctures. A 2nd stitch is placed after the first one and is tied with the foot in plantar flexion.

14. Surgical Intervention: Procedure Steps
If no assistant, STSR holds foot in equinus position during surgery
Longitudinal incision is made w/ #10 knife blade medial to Achilles Tendon and carried down to the paratenon.
Note: in comparison w/ flexor tendons in the hand which have an outside synovial sheath covering the tendon, the Achilles Tendon has no such sheath and is covered by the paratenon.
Ruptured ends of Achilles Tendon are identified.
Proximal end may be explored
Due to constant tension on Achilles Tendon, proximal end may retract upward along gastrocenemius muscle and require retrieval with tendon-pulling forceps or other atraumatic clamp
Wheeless:
incision: - longitudinal incision is made just medial to achilles tendon; - a medially placed incision may be less likely to slough from the pressure that the repaired tendon exerts on the overlying skin; - additionally a medially placed incision is less likely to develop postop adhesions; - a laterally
- para-tenon: - w/o creating a flap, the incision is carried down to the para-tenon; - some surgeons will attempt to cut the paratenon straight over the tendon (as opposed to the the medial side in line with the incision); - evaluate tendon defect: - identify the level of the rupture of the Achilles tendon; - attempt to identify the plantaris tendon; - mobilize the proximal Achilles tendon by sweeping a finger circumferentially aroung the tendon border (thus breaking up adhesions); - using non-traumatic clamps, match the ends of the ruptured tendon to achieve optimal length;

15. Surgical Intervention: Procedure Steps
Another atraumatic clamp is placed on the other end of the ruptured tendon and ends are brought together to achieve original length
Surgeon has several suture repair techniques to choose from.

16. Krachow whip stitch
Consider using a Krachow whip stitch, along each tendon edge, using No 5 Tycron or Ethibond on a Non Cutting Needle; - alternatively consider a running "Tajima stitch" which provides good strength but does not create the overlying prominent sutures
suture repair: - consider using a Krachow whip stitch, along each tendon edge, using No 5 Tycron or Ethibond on a Non Cutting Needle; - alternatively consider a running "Tajima stitch" which provides good strength but does not create the overlying prominent sutures;
- Becker suture technique: - has been studied extensively for flexor and extensor tendon lacerations in the hand; - in the study by Singer et al 1998, the core suture technique was the most important element in establishing both strength and stiffness of the repair; - repair consists of criss-crossing running suture using a double armed needle; - sutures should be placed 0.75 cm from the cut edge of the tendon; - as noted in the report by Howard and Greenwald 1997, the MGH tendon repair technique (crossing running suture repair) was signficantly more resistant to gap formation than the Bunnel or the Krackow technique; - MGH tendon repair has superior suture purchase which is probably related to superior resistance to gap formation; - the tendon edges are approximated together w/ non traumatic clamps, before the suture arms are brought thru the tendon edges; - before tying the sutures, note the degree of equinus in the opposite ankle (it is essential to optimize tension); - each side is tied simultaneously to optimize tendon oposition; - following the core suture repair, run a 2-0 Vicryl suture on a non-cutting needle to further oppose the irregular edges of the ruptured tendon;

17. Procedural Steps
Next surgeon closes paratenon over the site of the tendon repair to aid in healing and preventing adhesions from forming.
Wound closed in layers and splint dressing is applied while in equinus position
fascial augmentation: - gastrocnemius aponeurosis: - fashion a rectangular 1-2 cm wide by 8 cm long flap from the proximal tendon and gastrocneumius aponeurosis which is raised to with in 3 cm of the rupture site; - don't cut out the previously inserted core sutures during this step; - immediately beneath the gastroc fascia, the surgeon will note the soleus muscle; - the proximal flap edge is then flipped distally across the repair site and sutured down; - the fascial defect is closed with interrupted sutures; - stated advantageous include less adhesion formation and a stronger repair; - plantaris tendon augmentation: - can be used to augment the repair by weaving it across the repair site; - it can be left attached either proximally or distally; - alternatively the plantaris tendon can be fanned out to make a 2.5 cm membrane that is then sutured around the repair site; - attempt to close the paratenon, especially over the tendon repair site; - this is important both for healing and prevention of adhesions; - references: - Repair of the calcaneal tendon. An improved technique. - Repair of Achilles tendon ruptures with Dacron vascular graft. - A flap augmentation technique for Achilles tendon repair. Postoperative strength and functional outcome. - A new treatment of ruptured Achilles tendons. A prospective randomized study. - Surgical repair of Achilles tendon ruptures. - Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study. - A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. - Repair of acute Achilles tendon ruptures. CA Soma and BR Mandelbaum. Orthop Clin North Am. Vol p

18. Counts Initial: sharps and sponges—instruments depends on site
First closing
Final closing
Sponges
Sharps

19. Specimen & Care
Identified as N/A
Handled: routine, etc.

20. Expected Outcome
Most tendon repairs are successful, allowing full joint function: for Achilles Tendon: after 10 days the splint is removed and approx 6 weeks post op pt may be able to perform gradual weight bearing
Allrefer.com
Tendon repairs can often be done in an outpatient setting and hospital stays, if any, are short. Healing, however, can take as long as 6 weeks, during which the injured part may need to be immobilized in a splint or a cast.
Postoperative therapy is frequently necessary to minimize scar tissue and maximize function after repair.
For percutaneous tendon repair, the dressing is applied and the foot is placed in a plantar flexed pre-formed padded splint.
Benefits of Percutaneous achilles tendon repair: full incision is not made—reducing chance of infection or scar formation, the tendon sheath that forms at the time of the tendon sheath rupture is kept intact, permitting rapid healing of the tendon. No general anesthetic is needed, the Rehab program is accelerated, Full return to sports is expected (pool at 6 wks, golf/cycling at 3 mos, tennis 6 mos).

21. Possible complications
Tendon Repair: Risks
Risks for any anesthesia include the following:
Reactions to medications
Problems breathing
Risks for any surgery include the following:
Bleeding
Infection
Additional risks include the following:
Formation of scar tissue which prevents smooth movements (adequate tendon gliding)
Partial loss of function in the involved joint
People most at risk:
Age: 60 or older
Obesity
Smoking
Alcoholism
Poor nutrition
Recent or chronic illness
Use of certain medications, including blood pressure-lowering drugs, insulin, cortisone, and some sedatives
Use of mind-altering drugs
Percutaneous Achilles Tendon: temporary numbness over lateral border of the foot, if one of the sensory nerves gests caught by a suture (resolves); Irritation from a suture knot; Have had no infections or re-ruptures since 92.

22. Postoperative Care
post operative care: - posterior splint for 10 days in maximum equinus to reduce tension on the incision; - cam walker w/ 15 deg of equinus (or gravity equinus), non wt bearing; - pts are permitted non wt bearing ankle ROM exercises out of the cam walker; - after approximately 3-4 weeks the leg is brought out of equinus to a neutral positoin; - gradual wt bearing is allowed at 6 weeks; - consider DVT prophylaxis for 6 weeks; - in the report by M. Speck et al (Am J Sports Med 1998), the authors report on their experience with early full wt bearing; - the authors prospectively evaluated the clinical outcomes of 20 pts w/ early full wt bearing and functional treatment after surgical repair of acute Achilles tendon rupture; - patients underwent open repair using a Kessler-type suture and simple apposition sutures; - postoperative regimen included a plantigrade splint for 24 hours and 6 weeks of early full wt bearing in a removable walker; - at 1 day after surgery, early full wt bearing alternating with passive range of motion exercises was initiated; - patients were instructed to move the ankle four times a day between 20° of plantar flexion and 10° of extension; - there were no reruptures;

23. Resources www.Allrefer.com Community.healthgate.com STST pp. 841-842
Dr Calkins Preference Card
MAVCC Unit 10, OBJ 21
Myfootshop.com