Operation Report
A few others have posted their operation reports on their respective blogs, so I thought I’d add mine as well. I’m not sure if there is any valuable data in here, but it may be interesting to compare with the other reports. The report also gives a little more detail about the less invasive procedure performed by my surgeon, including some information about the suture technique. Feel free to leave a comment if you have any questions regarding the procedure.
DATE OF SERVICE: 01/09/2008
PREOPERATIVE DIAGNOSIS: Right Achilles tendon rupture.
POSTOPERATIVE DIAGNOSIS: Right Achilles tendon rupture.
PROCEDURE PERFORMED: Percutaneous repair, right Achilles tendon.
INDICATIONS FOR OPERATION: This is a 34-year-old active engineer who ruptured his right Achilles tendon six days ago playing volleyball. I saw him in the office on Monday, and we discussed the merits of operative versus nonoperative management. He would like to proceed with operative repair to decrease his rate of a rupture and hopefully improve his final outcome in terms of strength so that he can continue to run and jump. He is now admitted for percutaneous repair of his right Achilles tendon.
FINDINGS: The patient had a small amount of ecchymosis about his hindfoot. He had a palpable defect in his Achilles tendon as well as a positive Thompson sign. The repair was performed with the patient in the prone position using three 1 cm horizontal incisions. The first incision was made directly at the site of the rupture and the other two incisions were made 5 cm proximal and 5 cm distal. The most proximal incision was placed on the medial side of the tendon to avoid a possible injury to the sural nerve. The tendon was repaired with two square box sutures placed percutaneously with the ankle in maximum plantarflexion. The sutures were reapproximated restoring continuity at the tendon. The ankle was then immobilized in plantarflexion in a short leg plaster.
DESCRIPTION OF PROCEDURE: The patient was seen in the preop area where his identity was confirmed, his operative site was marked and his consent was reviewed. He was brought to surgery. He was given prophylactic antibiotics (1 gm Ancef). He was intubated and then placed in the prone position. His right foot was prepped and draped in the sterile fashion with his leg supported on an operating room positioning aid so that his hindfoot was free.
A skin marker was used to outline three horizontal incisions placed as described above. The incisions were made with a #15-blade scalpel and the subcutaneous tissue gently spread especially proximally to avoid an injury to his cutaneous nerves.
A #2 Fiberwire suture was then utilized on a free needle. It was passed from the middle incision at the site of the defect out the proximal incision. A grasping stitch was then placed horizontally across the musculotendinous junction and then returned down the opposite site to exit the middle wound. The same suture was then passed back into the middle wound, out the distal incision, across the distal tendon, and then back up to the middle wound, thereby creating a box type of suture.
A second stitch was then placed in the exact same manner except from the opposite side of the tendon.
With the ankle kept in maximum dorsiflexion with the towels, and with my nursing assistant retracting one suture, I tied the opposite suture. The second suture was then tied. I took care to make sure there were no adhesions between the sutures and the subcutaneous tissue. With the ankle in plantarflexion the horizontal incisions were all coapted naturally. They were nonetheless closed with a subcutaneous Vicryl suture and Steri-Strips. The tendon was palpably taut. The Thompson test was now negative, i.e., squeezing the calf was associated with plantarflexion of the ankle documenting continuity of the tendon. The wound was dressed with sterile bandages and then a Robert Jones plaster splint was applied to the foot in the resting position of about 20 degrees of equinus. He was then returned to the supine position, extubated, and brought to the Postanesthesia Care Unit (PACU) in stable condition.
The plan will be to discharge him home. He will be seen in the office in two weeks. At that time, we will anticipate placing him in a short-leg cast for another few weeks and then slowly bring him up to neutral position. We will not allow weightbearing for six to eight weeks.
Was anyone admitted to the hospital after surgical repair of a rutured achilles tendon? I am about to have surgery next week. I was also wondering upon returning home the day of surgery how much help I would need. Thanks so much for any info. I am a little spooked.
Generally, you are sort of “admitted” to the hospital for the surgery and later released after you have recovered from the anesthetic. It is highly unlikely that you would be kept overnight. You cannot drive yourself to the hospital for surgery unless someone goes with you who will be driving you home. After you get home you are likely to sleep for several hours because it actually takes about 24 hours for the anesthetic to completely wear off. After surgery you are better off if you just stay in bed with your foot elevated, unless absolutely necessary, like to go to the bathroom, for a couple of days. The surgery itself is a piece of cake. There will be a few days afterward when the pain can be pretty intense so be sure you have pain medication that works for you as not everything works for everyone.
Yes, Donna, what GerryR said. On the other hand, if you really want to avoid the surgery, the newest evidence has now shown that you can do just as well on performance (strength, Range of Motion, re-rupture rate) with lower risks of complication (skin infections, Deep Vein Thrombosis) and way less pain by going the non-surgical route.
I’ve posted the links to the latest (Canadian) study on my first blog here. (If you have trouble finding it, go to the home page and search for normofthenorth and click.)
I don’t want to turn you into The Patient From Hell, but hey, if we don’t act as our own advocates, who will?
I went to one of the fanciest Sports Medicine surgeons in the spiffy city of Toronto, and he told me he stopped doing Achilles Tendon reattachment surgery 4 months before I met with him on Dec. 10th, after discussing the latest study with the study’s authors!
BTW, I had my other AT reattached surgically after I tore it 8 years ago, based on the state of the evidence in late 2001. But the times they are a-changin’! And most clinical doctors don’t have time or inclination to keep up with the literature, even in their own fields. (And if a study says that what you do for a living maybe isn’t helpful, and you’re human. . .)
Good luck!
don’t know where to put this but can anyone tell me how to out a night splint on!?
[WORDPRESS HASHCASH] The poster sent us ‘0 which is not a hashcash value.
If it’s just an angled piece of stuff, I assume it’s usually held on with elastic (”Tensor”) bandages, to hold your leg to the splint.
Doug53 — check his blog — started out with that arrangement post-op, which he removed frequently for exercises and vibration, etc.