Bernard C. Ong, MD, and Elly Trepman, MD

Am J Orthop. 2001;30(5):433-434

Abstract

For Achilles tendon surgery, an S-shaped incision may be made crossing the midline proximal to the transverse skin creases above the top of the heel counter. This incision provides wide exposure of the tendon and enables wound closure with minimal skin tension. After surgery, direct external pressure on the wound and dependent swelling of the Achilles tendon region, which may increase risks for wound dehiscence and infection, are minimized by laying the patient in the lateral decubitus or prone position to elevate the heel.

Surgery for Achilles tendon rupture or tendinosis may be complicated by postoperative wound problems, including infection, dehiscence, sinus formation, skin slough, adherent scar, and sural nerve injury.¹ With repair of acute Achilles tendon rupture, wound complications may occur in 13% to 20% of cases and may contribute to treatment morbidity, including débridement, antibiotics, and flap coverage.^2,3 Risks for wound dehiscence and necrosis may increase as a result of skin-closure tension. Furthermore, after surgery, the patient usually lies supine, which may contribute to wound breakdown by placing direct external pressure on the wound and by permitting edema to increase because of the dependent position of the surgical site.^4,5

In this article, we describe 2 techniques that may minimize the risks for these wound problems. An S-shaped incision may be repaired distal to proximal with minimal tension at the skin edges. External pressure may be avoided, and wound swelling may be decreased, by positioning the patient in the lateral decubitus or prone position after surgery.

Methods

To expose the Achilles tendon, an S-shaped skin incision is made beginning distally along the medial edge of the tendon and crossing the midline well proximal to the transverse Achilles skin creases to avoid the top edge of the heel counter of a shoe. The incision is completed proximally along the lateral side of the tendon (Figure). If a posterolateral short longitudinal heel scar exists from previous surgery,⁶ the incision is started laterally along the previous scar and is ended proximally along the medial side of the tendon. Full-thickness skin and subcutaneous flaps are elevated medially and laterally as needed to expose the peritenon and tendon. The sural nerve is mobilized and protected during dissection (Figure).

After tendon repair or reconstruction is completed, the peritenon is closed using a 2-0 absorbable suture. The wound is closed, beginning at the distal end to avoid skin tension in this area. The subcutaneous layer is repaired with 2-0 absorbable sutures with the knots buried, and the skin is sutured with 4-0 nylon, using simple and vertical mattress sutures.7

The foot is maintained in the equinus position from the time tendon repair or reconstruction is completed until the end of the operation. A well-padded, bulky dressing is applied with gauze sponges, 3 or 4 abdominal pads (Surgipad, Johnson & Johnson Medical Inc., Arlington, TX) at the malleoli, heel, and dorsal foot, and cotton rolls (Webril^®, Kendall Company, Mansfield, MA). A plaster anterior slab and a U-splint are applied; direct contact between plaster and posterior incision is avoided. On the first postoperative day, the splint is removed, and a similarly well-padded short-leg fiberglass cast is applied with the foot and ankle in the plantar-flexed position, is univalved medially, and is taped closed. The patient is shown how to remove the tape and widen the univalved opening manually if cast tightness increases as a result of swelling. The wound is examined weekly through a window made in the cast, which is closed with a roll of fiberglass, and sutures are removed when the incision is healed, usually after 2 to 3 weeks.

Figure. S-shaped incision for Achilles tendon surgery in patient with acute right Achilles tendon rupture. (A) The incision, distal-medial to proximal-lateral, provides wide exposure of the Achilles tendon region. The sural nerve is noted as being superficial to the Achilles tendon as it courses to the lateral retromalleolar area. Retraction is used for photography but is minimized during the procedure to prevent traction injury to the skin. (B) Posterior view of the postoperative splint. The splint is clearly marked KEEP OFF BED in the posterior Achilles and heel regions as a reminder to the patient and hospital staff. (C) Posterior S-shaped incision healed 4 weeks after surgery.

The patient is told to avoid external pressure on the surgical incision for 6 weeks and is instructed how to do so while in bed–by lying prone or in the lateral decubitus position (Figure 1). If the patient has difficulty maintaining this position, the lower extremity is placed in a figure-of-4 so that the heel is in the lateral decubitus position, with the foot and heel overhanging 2 pillows under the calf region to avoid external pressure to the Achilles region.

Discussion

Advantages of the S-shaped incision include wide exposure of the Achilles tendon region and visualization of the sural nerve. Soft-tissue tension at the distal portion of the incision–the site of least flap thickness and perhaps the site at greatest risk for wound complications–is minimized. The central portion of the scar is less perpendicular to the posterior Achilles skin creases than with a longitudinal approach, minimizing tension at the scar.⁸ The approach also avoids a potentially painful scar at the posterior midline of the heel, heel counter, or transverse Achilles skin-creases.

During the postoperative period, avoiding direct pressure on the surgical wound seems to decrease the risk for pressure-induced wound complications. Positioning the heel upward or sideways may minimize dependent swelling at the surgical site. Frequent examination of the wound allows for early detection and management of problems and may minimize treatment morbidity.

References

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2.	Kellam JF, Hunter GA, McElwain JP. Review of the operative treatment of Achilles tendon rupture. Clin Orthop Rel Res. 1985; 201:80-83.
3.	Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture: a review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Rel Res. 1986;207:156-163.
4.	Jahss MH. Surgical principles and the plantigrade foot. In: Jahss MH, ed. Disorders of the Foot & Ankle. 2nd ed. Philadelphia, PA: Saunders; 1991:253.
5.	Smith DG, Stuck RM, Ketner L, et al. Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. J Bone Joint Surg Am. 1992;74:571-576.
6.	Richardson EG. Heel pain. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. 7th ed. St. Louis, MO: Mosby; 1999:862-879.
7.	Trepman E, Mizel MS, Mann RA. A method to facilitate suture removal. Foot Ankle Int. 1995;16:103-104.
8.	Gibson T. Physical properties of skin. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, PA: Saunders; 1990:207-220.

Dr. Ong is Resident, Department of Orthopaedic Surgery, New York University, Hospital for Joint Diseases, New York, New York. Dr. Trepman is Associate Professor, Section of Orthopaedic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Canada.