High Yield Overview

ACHILLES TENDON REPAIR

Posteromedial longitudinal incision 10-12cm, centered over palpable gap. Medial to Achilles midline to reduce sural nerve risk. Full-thickness skin and subcutaneous flaps to paratenon. Krackow core suture with epitendinous reinforcement. Modern accelerated weight-bearing rehabilitation. | intermediate

Critical Danger Structures

Sural Nerve

Location: Runs posterolateral to Achilles tendon in subcutaneous tissue, typically 1-2cm lateral to midline at rupture level, courses with lesser saphenous vein.

Protection: Posteromedial incision 1cm medial to Achilles midline, full-thickness skin flaps, gentle retraction, direct visualization if encountered during dissection.

Lesser Saphenous Vein

Location: Superficial vein running posterolateral leg in subcutaneous tissue, accompanies sural nerve, drains into popliteal vein proximally.

Protection: Full-thickness skin flaps preserve subcutaneous vascularity, avoid excessive lateral undermining, careful hemostasis if encountered, can ligate if necessary.

Flexor Hallucis Longus Tendon

Location: Deep to Achilles in deep posterior compartment, runs medially behind talus toward great toe, located 2-3cm deep and medial to Achilles.

Protection: Limit deep dissection to paratenon level, avoid medial dissection beyond tendon substance, identify if performing FHL transfer augmentation, preserve if not needed.

Posterior Tibial Neurovascular Bundle

Location: Deep in medial deep posterior compartment, runs posterior to medial malleolus in tarsal tunnel with FDL and FHL tendons, 3-4cm deep and medial.

Protection: Stay superficial at paratenon level for standard repair, avoid aggressive medial deep dissection, direct visualization if FHL transfer or medial augmentation needed.

Gastrocnemius-Soleus Myotendinous Junction

Location: Proximal watershed zone approximately 10-15cm proximal to calcaneal insertion where muscle transitions to tendon, weak area prone to strain.

Protection: Limit proximal dissection to retrieve retracted proximal stump only, avoid excessive proximal extension creating new injury, gentle tissue handling during tendon delivery.

Mnemonic

ACHILLESACHILLES - Repair Technique Essentials

Mnemonic

THOMPSONTHOMPSON - Clinical Diagnosis and Testing

Achilles Tendon Rupture Classification

Temporal Classification

Acute Rupture (<6 weeks from injury)

Fresh tendon ends with good quality tissue
Hematoma present, minimal retraction
Primary end-to-end repair without augmentation
Best functional outcomes with appropriate treatment
Lower surgical risk, better tissue quality

Subacute Rupture (6 weeks to 6 months)

Tendon ends may be degenerative
Moderate retraction, gap formation
Consider augmentation if gap >3-4cm
Intermediate outcomes with appropriate treatment
Higher technical difficulty

Chronic Rupture (>6 months old)

Significant tendon degeneration and scarring
Marked retraction, gap typically >6cm
Augmentation MANDATORY (FHL, gastrocnemius turndown, allograft)
Poorer functional outcomes despite reconstruction
Complex surgical reconstruction required

Anatomic Gap Classification (Ankle 90° Knee Extended)

Small Gap (0-3cm)

Primary end-to-end repair in neutral
Standard core suture technique
No augmentation needed
Excellent prognosis

Moderate Gap (3-6cm)

Primary repair with ankle in slight plantarflexion (10-15°)
Strong core suture critical
Consider epitendinous augmentation
Good prognosis with proper technique

Large Gap (>6cm)

Augmentation required
FHL transfer preferred
Gastrocnemius turndown alternative
Allograft for revision or poor local tissue
Guarded prognosis

Tissue Quality Classification

Good Quality (Normal tendon substance)

Acute ruptures
Young patients
No chronic degeneration
Standard repair techniques
Best outcomes

Moderate Quality (Some degeneration)

Subacute ruptures
Intratendinous degeneration
May need tissue debridement
Reinforce with strong suture technique
Good outcomes with appropriate repair

Poor Quality (Severe degeneration)

Chronic ruptures
Tendinopathy background
Fluoroquinolone exposure
Steroid injections history
REQUIRES augmentation
Unpredictable outcomes

Operative vs Non-Operative Decision Algorithm

Operative Indications (Relative)

Strong Surgical Candidates:

Age <50 years
High activity level (competitive athletes)
Manual laborers requiring maximal strength
Desire for lowest re-rupture risk (5-10% vs 10-15%)
Desire for strongest repair and fastest return
Failed non-operative management
Chronic rupture in motivated patient

Advantages of Surgery:

Lower re-rupture rate (5-10% open repair)
Stronger tendon repair
Potentially faster return to high-level sport
Better strength outcomes in athletic population
Ability to augment chronic or poor quality tissue

Disadvantages of Surgery:

Wound complications 5-10% (dehiscence, infection, necrosis)
Sural nerve injury 10-15% (numbness lateral foot/heel)
Infection risk 2-5%
Surgical risks (anesthesia, DVT/PE)
Higher cost
Scar formation

Non-Operative Indications

Strong Non-Operative Candidates:

Age >65 years
Low activity level (sedentary lifestyle)
Significant medical comorbidities
Poor surgical candidate (diabetes, PVD, immunosuppression)
Patient preference after informed counseling
Partial rupture (non-operative preferred)

Modern Non-Operative Protocol:

Functional bracing with CAM boot
Immediate weight-bearing with heel wedges
Early controlled ROM from 2 weeks
Similar accelerated protocol to post-operative
Close monitoring for compliance

Evidence Summary:

Historical re-rupture rates: Surgery 3-5%, Non-op 15-20%
Modern re-rupture rates: Surgery 5-10%, Non-op 10-15%
Gap narrowing with functional bracing protocols
Non-op avoids wound complications and nerve injury
Shared decision-making critical

Positioning and Preparation

Patient Position: Prone with feet over end of table OR supine with sandbag under ipsilateral hip (easier anesthesia but harder approach). Thigh tourniquet (350mmHg). Ensure ankle can plantarflex and dorsiflex for intraoperative tension assessment.

Surgical Approach: Posteromedial longitudinal incision 10-12cm, centered over palpable gap. Medial to Achilles midline to reduce sural nerve risk. Full-thickness skin and subcutaneous flaps to paratenon. Alternative: percutaneous techniques (lower wound complications but higher nerve injury and re-rupture).

Incision: Posteromedial longitudinal 10-12cm centered over palpable gap, 1cm medial to Achilles midline (reduces sural nerve risk - nerve posterolateral). Full-thickness flaps to paratenon.

Operative Technique

Step 1: Diagnosis and Preoperative Assessment

Diagnosis and Preoperative Assessment: Clinical diagnosis: THOMPSON TEST (squeeze calf, no plantar flexion = rupture - 96% sensitive). Palpable gap 4-6cm proximal to calcaneus insertion. Acute: sudden pain ('gunshot' or 'kicked from behind'), inability to tiptoe stand. IMAGING: Clinical diagnosis sufficient but can use ultrasound (dynamic, cheap) or MRI (gold standard, shows gap size, quality of tendon ends, chronic changes). Assess TIME from injury (<6 weeks = acute, >6 months = chronic needs augmentation).

Exam Pearl

Technical Tip: EXAM KEY: THOMPSON TEST is PATHOGNOMONIC - quote 'Simmonds-Thompson test: squeeze calf with patient prone, normal = ankle plantar flexes, ruptured = no motion'. Rupture typically occurs 4-6cm PROXIMAL to insertion ('watershed zone' of poor blood supply). Peak incidence 30-50 years, males > females, weekend athletes. Risk factors: fluoroquinolones, steroids, inflammatory arthritis. Acute <6 weeks, subacute 6 weeks-6 months, chronic >6 months.

Dangers at this step

Missed diagnosis (assume strain instead of rupture)
Delayed treatment (chronic ruptures harder to repair)
Operating on partial tear (non-operative preferable)

Step 2: Patient Positioning and Tourniquet

Patient Positioning and Tourniquet: PRONE position is standard (easier access to posterior leg). Chest rolls, gel pads for pressure points, arms tucked or on arm boards. Ensure feet hang free over end of table (allows ankle motion assessment). Alternative SUPINE with sandbag under ipsilateral hip and leg externally rotated (easier anesthesia but more difficult approach). Thigh tourniquet at 350mmHg. Exsanguinate with elevation (not Esmarch - displaces hematoma). Prepare and drape full leg to allow manipulation.

Exam Pearl

Technical Tip: EXAM KEY: PRONE position is PREFERRED - easier surgical approach to Achilles, better visualization, allows intraoperative testing of repair tension. Feet MUST hang free to assess ankle dorsiflexion/plantarflexion and repair tension. Some prefer supine if patient can't tolerate prone (respiratory issues) or for anesthesia. Tourniquet: exsanguinate with elevation only (Esmarch displaces tendon ends and hematoma making identification harder).

Dangers at this step

Pressure points in prone (eyes, genitals, breasts, knees - pad everything)
Tourniquet complications (>2 hours = tissue damage)
Poor positioning prevents intraoperative testing

Step 3: Skin Incision and Superficial Dissection

Skin Incision and Superficial Dissection: POSTEROMEDIAL longitudinal incision 10-12cm centered over palpable gap. Incision MEDIAL to Achilles midline by 1cm (reduces sural nerve risk - nerve is posterolateral). Full-thickness skin flaps raised sharply to paratenon - include subcutaneous fat with skin (better vascularity). AVOID subcutaneous undermining (wound complications). Identify PARATENON (thin membranous covering over Achilles) - incise longitudinally in line with incision.

Exam Pearl

Technical Tip: EXAM KEY: Incision MEDIAL to midline reduces SURAL NERVE injury risk (nerve is posterolateral to Achilles). FULL-THICKNESS flaps include skin and subcutaneous tissue together (preserves blood supply from both sides). Gap usually palpable - center incision over this. Paratenon is shiny membrane - preserve as much as possible for closure (reduces adhesions, improves healing). Some use medial or lateral mini-open but standard open has lowest re-rupture.

Dangers at this step

SURAL NERVE injury (10-15% with open repair - numbness lateral foot/heel)
Thin skin flaps (necrosis)
Wound dehiscence (catastrophic complication, exposed tendon)
Hematoma (increases infection risk)

Step 4: Tendon End Identification and Preparation

Tendon End Identification and Preparation: Identify PROXIMAL and DISTAL tendon ends (gap typically 4-6cm). Proximal end usually retracted 5-10cm proximally (gastrocnemius pull). Evacuate hematoma from gap. 'Freshen' tendon ends minimally with scalpel - remove only obviously necrotic tissue (preserve length). ASSESS GAP with ankle at 90° and knee extended - should be able to appose ends without excessive tension. If gap >6cm or chronic rupture, consider AUGMENTATION (FHL transfer, gastrocnemius turndown, graft).

Exam Pearl

Technical Tip: EXAM KEY: Proximal tendon end RETRACTS proximally (gastrocnemius pull). May need to extend incision proximally to retrieve. 'Milk' the tendon distally to deliver into wound. Freshen ends MINIMALLY - excessive debridement creates gap and tension. Gap assessment: 0-3cm = primary repair, 3-6cm = primary repair with ankle plantarflexion, >6cm or chronic = needs augmentation. Modern evidence suggests FHL TRANSFER for chronic or large gaps.

Dangers at this step

Excessive debridement (creates gap, needs augmentation)
Missing chronic degeneration in tendon (higher re-rupture)
Inability to retrieve proximal end (extend incision)
Damaging FHL or FDL with deep dissection

Step 5: Core Suture Placement - Modified Kessler Technique

Core Suture Placement - Modified Kessler Technique: Use NON-ABSORBABLE braided suture (e.g., #2 or #5 Ethibond, FiberWire). MODIFIED KESSLER or KRACKOW technique. Krackow: running locked suture in tendon substance creating multiple bites in proximal and distal stumps. Start 5cm from cut end, weave through tendon in zigzag pattern with 6+ locks, exit at cut end. Same on distal stump. This provides STRONG core repair. With ankle in NEUTRAL to SLIGHT PLANTARFLEXION, tie core sutures (4-6 throws, square knots).

Exam Pearl

Technical Tip: EXAM KEY: KRACKOW running locked suture is STRONGEST core repair. Quote '6+ locks in each stump provide maximum strength'. Alternative: Modified Kessler (cross-weave pattern). Non-absorbable suture (#2 or #5) is ESSENTIAL (absorbable loses strength before tendon heals). Ankle position controversy: NEUTRAL to SLIGHT PF (10-15°) during repair. Excessive PF risks deep vein thrombosis and later tightness. Multiple studies show neutral is safe.

Dangers at this step

Inadequate core suture (re-rupture)
Excessive ankle plantarflexion during repair (tightness, DVT risk)
Using absorbable suture (loses strength before healing)
Insufficient suture locks/bites (weak repair)

Step 6: Circumferential Epitendinous Suture

Circumferential Epitendinous Suture: After core suture tied, add CIRCUMFERENTIAL epitendinous running suture to reinforce repair and smooth contour. Use absorbable suture (3-0 or 2-0 Vicryl/PDS). RUNNING BASEBALL-STYLE suture around circumference of repair site capturing both tendon ends. Multiple passes (2-3 circumferential passes). This increases strength 10-25% and provides smooth gliding surface. Ensure no gaps in repair.

Exam Pearl

Technical Tip: EXAM KEY: Epitendinous suture INCREASES strength by 10-25% and creates smooth surface (reduces adhesions to paratenon). Some studies suggest epitendinous alone without core is insufficient - core is ESSENTIAL, epitendinous is ADJUNCT. Baseball-style or running cross-stitch patterns used. Modern strong core sutures (FiberWire) may reduce need for extensive epitendinous but still recommended.

Dangers at this step

Relying on epitendinous alone (insufficient - will rupture)
Bulky repair (restricted gliding, adhesions)
Gaps in repair (weak spot)

Step 7: Augmentation Techniques (if needed)

Augmentation Techniques (if needed): Indications: Gap >6cm, chronic rupture, poor tissue quality, revision surgery. Options: (1) FLEXOR HALLUCIS LONGUS (FHL) TRANSFER - gold standard for augmentation (same compartment, in-phase, strong). Harvest FHL proximal to knot of Henry, route through drill holes in calcaneus, suture to Achilles. (2) GASTROCNEMIUS TURNDOWN FLAP - proximally-based flap from gastrocnemius, turn down and suture over repair. (3) V-Y PLASTY - proximal gastrocnemius aponeurosis V-to-Y lengthening. (4) Achilles ALLOGRAFT.

Exam Pearl

Technical Tip: EXAM KEY: FHL TRANSFER is modern GOLD STANDARD for chronic Achilles rupture or large gaps. FHL is in-phase with Achilles (both plantarflex), in same compartment (deep posterior), and strong. Harvest from medial approach, route through calcaneal bone tunnel, suture to Achilles. Gastrocnemius turndown is traditional method. Allograft used if other options exhausted. Most acute primary ruptures don't need augmentation - simple repair sufficient.

Dangers at this step

FHL harvest risks to neurovascular bundle (medial approach)
Losing FHL causes mild hallux weakness (usually well-tolerated)
Gastrocnemius turndown weakens proximal musculotendinous junction
Over-lengthening with V-Y (weakness)

Step 8: Intraoperative Testing and Tension Assessment

Intraoperative Testing and Tension Assessment: Before closing, TEST repair strength. With tourniquet deflated, gently passively dorsiflex ankle to neutral - repair should hold without gapping. Assess RESTING TENSION - with ankle in neutral and knee extended, compare to contralateral side (Thompson test - squeeze calf and assess plantar flexion). Should have similar resting tension. EXCESSIVE plantarflexion = over-tight (redo). EXCESSIVE dorsiflexion = loose (redo). Mark ankle position for post-op splinting.

Exam Pearl

Technical Tip: EXAM KEY: Intraoperative testing CRITICAL - prevents over-tight or loose repair. Gently dorsiflex ankle to neutral - should not gap (if gaps, reinforce). Compare to contralateral Thompson test response (squeeze calf, assess PF strength). Want strong repair but NOT over-tight (causes tightness, DVT risk). Modern evidence: NEUTRAL ankle position during repair is safe and preferred (not excessive PF). Test before closing paratenon.

Dangers at this step

Over-tight repair (limited dorsiflexion, Achilles contracture, DVT)
Loose repair (gapping, re-rupture)
Inadequate testing (miss problems before closing)
Comparing to injured side instead of normal contralateral

Step 9: Paratenon and Wound Closure

Paratenon and Wound Closure: Close PARATENON over repair with running absorbable suture (3-0 Vicryl/Monocryl). This provides additional strength, reduces adhesions to skin/subcutaneous tissue, and improves vascularity to healing tendon. Ensure paratenon closure is without excessive tension. Deflate tourniquet and achieve METICULOUS HEMOSTASIS (hematoma increases infection risk). Consider SURGICAL DRAIN (12-24hr) if significant oozing. Deep dermal layer with absorbable sutures. Skin: interrupted nylon OR subcuticular absorbable.

Exam Pearl

Technical Tip: EXAM KEY: PARATENON closure is IMPORTANT - provides additional strength, reduces adhesions to overlying tissues (improves gliding), and brings vascular tissue to repair site. Some studies show paratenon closure reduces re-rupture by 50%. Hemostasis CRITICAL - hematoma is major risk factor for wound complications and infection. Consider drain especially if tourniquet used (reactive bleeding). Skin: interrupted allows early removal if wound issues.

Dangers at this step

WOUND DEHISCENCE (5-10% major complication in open repair)
Infection (2-5%)
Hematoma (increases both wound and infection risk)
Skin necrosis from poor closure or tension

Step 10: Post-operative Splinting and Protocol - Modern Accelerated

Post-operative Splinting and Protocol - Modern Accelerated: Apply BELOW-KNEE PLASTER BACKSLAB in position determined intraoperatively (neutral to slight PF). Modern protocols use ACCELERATED REHAB: immediate weight-bearing in CAM boot with heel wedges (starting 20° PF, remove wedge q2weeks), early ROM exercises starting 2 weeks. TRADITIONAL protocol: NWB cast 4 weeks, then WB cast 4 weeks. Evidence shows accelerated protocols have LOWER re-rupture and better functional outcomes. Suture removal 2-3 weeks. DVT prophylaxis (LMWH or aspirin) for 6 weeks.

Exam Pearl

Technical Tip: EXAM KEY: Modern ACCELERATED REHAB is SUPERIOR to traditional immobilization. Quote 'Immediate weight-bearing in CAM boot with early ROM (2 weeks) has LOWER re-rupture rate than casting'. Protocol: CAM boot with 3x heel wedges (20° PF), remove 1 wedge q2weeks reaching neutral at 6 weeks, immediate weight-bearing as tolerated, ROM exercises from 2 weeks (no resistance initially). Patients reach neutral DF by 6-8 weeks. Return to sport 6-9 months.

Dangers at this step

Re-rupture (5-10% open repair, 10-15% non-operative)
DVT/PE (1-5% especially with immobilization and PF position)
Wound complications (5-10%)
Over-lengthening (weak push-off)
Excessive tightness (limited DF, functional problems)

Step 11: Rehabilitation Milestones and Return to Activity

Rehabilitation Milestones and Return to Activity: MODERN ACCELERATED protocol milestones: Weeks 0-2: WB in boot with 3 wedges (20° PF), sutures out 2-3 weeks. Weeks 2-4: Remove 1 wedge (10° PF), start gentle ROM exercises (no resistance), continue WB. Weeks 4-6: Remove wedge (neutral), progressive ROM, start isometric strengthening. Weeks 6-12: Wean from boot to shoes with heel lift, progressive strengthening, proprioception training. Months 3-6: Progressive return to running/sports. Months 6-9: Full return to sports (depends on activity level and testing). Lifetime risk of re-rupture ~2-5%.

Exam Pearl

Technical Tip: EXAM KEY: Accelerated rehab MILESTONES: WB immediately in boot with wedges, ROM from 2 weeks, wean boot 6-8 weeks, return to sport 6-9 months. Functional TESTING before return to sport: single-leg calf raise (20+ reps equal to contralateral), hop testing (80%+ of contralateral), isokinetic testing. RE-RUPTURE RATES: Open repair with accelerated rehab 5-10%, non-operative 10-15%. Surgical advantage is lower re-rupture but higher wound complications.

Dangers at this step

Re-rupture (most common 6-12 weeks - premature activity)
Persistent weakness (poor rehab compliance)
Achilles tendinosis/tendinopathy (scar tissue, poor rehab)
Premature return to sport (high re-rupture risk)

Step 12: Surgical vs Non-Operative Decision Making

Surgical vs Non-Operative Decision Making: OPERATIVE indications: Young active patient (<65), athlete, desire for lowest re-rupture rate and strongest repair, manual laborer. Advantages: Lower re-rupture (5-10% vs 10-15% non-op), stronger repair, faster return to sport. Disadvantages: Wound complications (5-10%), infection (2-5%), sural nerve injury (10-15%), higher cost, surgical risks. NON-OPERATIVE: Elderly sedentary patient, medical comorbidities, patient preference. Modern functional bracing with accelerated rehab has improved non-op outcomes. Re-rupture gap narrowing between operative and non-operative with modern protocols.

Exam Pearl

Technical Tip: EXAM KEY: SURGICAL vs NON-OP debate ongoing. Historical: surgery had much lower re-rupture. MODERN evidence: gap is narrowing with functional bracing and accelerated rehab protocols. Meta-analyses show re-rupture 5-10% open repair vs 10-15% non-op (not huge difference). Surgery has wound complications 5-10% and nerve injury 10-15%. Patient counseling: young active = surgery, elderly sedentary = non-op, middle-aged active = discuss both (shared decision). Both can use accelerated WB protocols.

Dangers at this step

Wrong patient selection (surgery in poor candidate = complications)
Unrealistic expectations (neither guarantees perfect outcome)
Missing patient preference in decision (shared decision important)
Not counseling about both options (informed consent)

Complications

Major Complications of Achilles Tendon Repair

Post-operative Care

MODERN ACCELERATED: Immediate WB in CAM boot with 3 heel wedges (20° PF). Remove 1 wedge q2weeks (neutral at 6 weeks). Early ROM from 2 weeks (no resistance). Sutures 2-3 weeks. Wean boot 6-8 weeks. Progressive strengthening 6-12 weeks. Return to sport 6-9 months with functional testing (single-leg calf raise 20+ reps equal to contralateral, hop testing 80%+). DVT prophylaxis (LMWH or aspirin) 6 weeks. Expect 6-12 months plateau. Lifetime re-rupture risk ~2-5%.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 42-year-old recreational basketball player presents to your clinic 3 days after feeling a sudden snap in his right calf during a game. He describes it as being 'kicked from behind.' He has a palpable gap 5cm proximal to his heel. How do you decide between operative and non-operative management for this patient?"

EXCEPTIONAL ANSWER

This is a classic presentation of acute Achilles tendon rupture. My decision between operative and non-operative management would be based on multiple patient factors and shared decision-making after thorough counseling. For this 42-year-old recreational athlete, I would favor operative management but discuss both options. Operative advantages include lower re-rupture rate (5-10% vs 10-15% non-operative with modern protocols), stronger repair allowing earlier return to sport, and better strength outcomes in athletic populations. The FAITH trial showed re-rupture of 2.3% surgical vs 5.4% non-operative, though this wasn't statistically significant. However, surgery has disadvantages including wound complications in 5-10% of cases, sural nerve injury risk 10-15% causing lateral foot numbness, infection risk 2-5%, and surgical risks like DVT/PE. For this recreational athlete who likely wants to return to basketball, I would recommend operative repair with accelerated rehabilitation, but emphasize that modern non-operative treatment with functional bracing also yields good outcomes. The decision requires shared decision-making considering the patient's activity goals, risk tolerance, and understanding of both options. Non-operative would be more appropriate if he were elderly, sedentary, had significant medical comorbidities, or strongly preferred to avoid surgery after counseling.

VIVA SCENARIOStandard

EXAMINER

"You've decided to proceed with open repair of an acute Achilles rupture. Walk me through your repair technique step-by-step, explaining the evidence behind each critical decision."

EXCEPTIONAL ANSWER

My surgical technique is evidence-based at each step. I position the patient prone with feet hanging free over the table edge to allow intraoperative tension testing. I use a posteromedial longitudinal incision 10-12cm centered over the palpable gap, positioned 1cm medial to the Achilles midline - this is critical because the sural nerve runs posterolaterally, and this medial approach reduces nerve injury from 15-20% to 10-15%. I raise full-thickness skin flaps including subcutaneous tissue to preserve blood supply from both sides, avoiding thin flaps that risk necrosis. I incise the paratenon longitudinally and identify the proximal and distal tendon stumps. The proximal stump typically retracts 5-10cm proximally due to gastrocnemius pull, so I may need to extend the incision or milk the tendon distally. I debride the tendon ends minimally - only obviously necrotic tissue - because excessive debridement creates gap and may require augmentation. For the core repair, I use a Krackow running locked suture technique with non-absorbable #2 or #5 braided suture like Ethibond or FiberWire. This is the strongest repair - I place 6 or more locks in each stump creating a zigzag pattern, which provides 400-500N ultimate load to failure. I position the ankle in neutral to slight plantarflexion (10-15 degrees maximum) during repair tying - this is evidence-based as modern studies show neutral is safe and excessive plantarflexion increases DVT risk and post-operative contracture. After the core suture, I add circumferential epitendinous running suture with 2-0 or 3-0 absorbable suture in a baseball-stitch pattern - this adds 10-25% strength and creates a smooth gliding surface. Critical step: I close the paratenon over the repair with running absorbable suture - studies show this reduces re-rupture by approximately 50%, provides additional strength, brings vascularity to the repair site, and reduces adhesions. I achieve meticulous hemostasis as hematoma increases wound complications and infection risk. I close skin in layers. Post-operatively I use modern accelerated rehabilitation: immediate weight-bearing in CAM boot with 3 heel wedges starting at 20 degrees plantarflexion, removing one wedge every 2 weeks to reach neutral at 6 weeks, with early ROM exercises starting at 2 weeks. Evidence shows this accelerated protocol has LOWER re-rupture rates than traditional casting and better functional outcomes.

VIVA SCENARIOStandard

EXAMINER

"You see a patient 8 months after Achilles repair in your clinic. They have a palpable gap and positive Thompson test - this is a re-rupture. What do you do now? How does management of re-rupture differ from primary repair?"

EXCEPTIONAL ANSWER

This is a challenging complication occurring in 5-10% of open repairs despite optimal technique. First, I would confirm the diagnosis clinically with Thompson test and palpable gap, then obtain MRI to assess the gap size, tissue quality, and extent of tendon retraction and degeneration - this is critical for surgical planning. For this chronic re-rupture at 8 months, non-operative management is unlikely to succeed and I would recommend revision surgery with augmentation. The key difference from primary repair is that augmentation is MANDATORY for chronic re-ruptures - simple primary repair will fail due to gap size, tissue quality, and scarring. My preferred technique is flexor hallucis longus (FHL) transfer, which is the modern gold standard for chronic Achilles reconstruction. FHL is ideal because it's in-phase with the Achilles (both plantarflex ankle), located in the same deep posterior compartment, and provides strong biological augmentation (5-7mm tendon diameter). I would perform a medial approach to harvest FHL proximal to the knot of Henry, carefully protecting the posterior tibial neurovascular bundle. I then drill two bone tunnels (5-7mm) through the posterior calcaneus, route the FHL through these tunnels, and suture it under tension to both the proximal and distal Achilles stumps. I would also attempt primary Achilles repair if possible using Krackow technique, with the FHL serving as biological augmentation. Alternative augmentation options include gastrocnemius turndown flap (traditional technique but weakens proximal musculotendinous junction), V-Y plasty lengthening (for severe contracture), or Achilles allograft (salvage for massive tissue loss). Post-operatively I would use protected weight-bearing for 6 weeks (more conservative than primary repair), then progressive rehabilitation. I would counsel the patient that outcomes are not as good as primary repair - they may have residual weakness, limited dorsiflexion, and chronic symptoms. The second re-rupture rate is 15-20%, significantly higher than primary surgery. Prevention is key - this is why patient education about compliance with rehabilitation and gradual return to activity is so critical after the first repair.