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Percutaneous Achilles Tendon Repair

Planning

B

Preoperative Plan

1

Radiographic templating

2

Execute surgical workthrough

  • describes the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • basic orthopedic set

2

Room setup and equipment

  • standard OR table
  • fluoroscopy

3

Patient positioning

  • place patient prone
  • place a thigh tourniquet

Technique

D

Skin Incisions

1

Make the first cut

  • make the first incision at the site of the rupture

2

Make the second cut

  • second incision 5 cm proximal to the first incision
  • make this incision over the medial half
  • this minimizes the risk of injury to the sural nerve

3

Make the third cut

  • third incision 5 cm distal to the rupture
E

Passage of the First Suture

1

Identify the tendon

  • use a small curved hemostat to define the track of the tendon

2

Suture the proximal end of the tendon

  • use a curved 90 mm cutting needle with number 1 nylon suture
  • pass a the needle through middle incision through the tendon substance and have it exit through the proximal incision
  • reintroduce the needle through the proximal incision
  • make sure that separate entry point is used
  • have the needle exit the middle incision

3

Suture the distal end of the tendon

  • introduce the needle through the middle incision
  • pass the needle through the distal stump of the tendon

4

Test the sutures

  • apply traction to the suture ends to ensure that good hold of both tendons is present
  • place an artery clip on the free ends of the suture
F

Passage of the Second Suture

1

Suture the proximal end of the tendon

  • use a curved 90 mm cutting needle with number 1 nylon suture
  • pass a the needle through middle incision through the tendon substance and have it exit through the proximal incision
  • reintroduce the needle through the proximal incision
  • make sure that separate entry point is used
  • have the needle exit the middle incision

2

Suture the distal end of the tendon

  • introduce the needle through the middle incision
  • pass the needle through the distal stump of the tendon

3

Test the sutures

  • apply traction to the suture ends to ensure that good hold of both tendons is present
  • place an artery clip on the free ends of the suture
G

Suture Tying

1

Tie the sutures

  • place the ankle in the plantar flexion
  • tie the sutures with the ankle in plantar flexion
H

Wound Closure

1

Close the wound

  • close the wound with nonabsorbale suture

2

Immobilize the ankle

  • place a cast with the ankle in plantar flexion

Patient Care

K

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • check neurovascular status to determine level of amputation

2

Order basic imaging studies

  • weightbearing images
  • AP/Lat views of foot, ankle, and tibia/fibula

3

Perform operative consent

  • describe complications of surgery
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • outpatient PT
  • schedule follow up in 2 weeks
M

Intermediate Evaluation and Management

1

Obtain focused history and performs focused exam

  • evaluate
  • vascular status
  • infection
  • neuropathy
  • trauma
  • vascular exam
  • need to assess associated injuries and comorbidities (diabetes)
  • documental baseline neurovascular exam

2

Appropriately interprets basic imaging studies

  • AP/Lat views of foot, ankle, and tibia/fibula
  • MRI of the to look for integrity of soft tissue and infection

3

Appropriately orders and interprets advanced imaging studies

  • CT and MRI w/ or w/o contrast)

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Postop: 2 week Postoperative Visit

  • wound management
  • diagnose and management of early complications
  • wound healing
  • infection
  • DVT
  • place a cast with the ankle in neutral position

6

Postop: 4 week Postoperative Visit

  • place a walking cast with the ankle in neutral

7

Treat postoperative complications

N

Advanced Evaluation and Management

1

Provides complex non-operative treatment

  • multiple co-morbidities
  • non-compliant
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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