A 38-year-old healthy male presented to the office three days after feeling a pop behind his left ankle after a noncontact injury during a recreational basketball game, complaining of pain in his Achilles. The patient had been ambulating with a short pneumatic walker and crutches that he had at home. On the physical exam, he was noted to have moderate swelling and ecchymosis, tenderness along the Achilles tendon, and a palpable gap in the midsubstance of the Achilles tendon. With the patient in the prone position with the knees bent, the resting tension of the Achilles was decreased on the injured side. He had a positive Thompson test, and bedside ultrasound revealed a full-thickness defect with approximately 1 cm gapping with forced plantar flexion. The patient had no preexisting symptoms of tendinopathy, was a nonsmoker, and had no risk factors for complication. A discussion was had with the patient regarding operative versus nonoperative management of his injury, and decision was made to proceed with operative repair of his Achilles tendon.
The patient was taken to the operating suite five days later for open Achilles tendon repair. He was positioned prone, and a midline incision was made over the Achilles tendon, dissecting sharply down through the paratenon. The Achilles rupture was identified, debrided, and repaired end to end with nonabsorbable suturetape  (Arthrex, Inc., Naples, FL) using a modified Krackow technique as described by Labib et al.. Sutures were passed proximal and distal to the Krackow stitches, using the gift box technique and tied with the ankle held in maximal plantar flexion (Figure 1). The ruptured plantaris tendon was weaved through the Achilles tendon proximally and out distally for further reinforcement of the repair. A 2-0 braided absorbable suture was used to close the paratenon and the subcutaneous tissue. The skin was closed with a series of nylon sutures with a tensionless repair. The patient was placed in an AO plaster splint with the ankle positioned in plantar flexion. He was instructed to remain nonweight bearing for two weeks following surgery.
At 2 weeks postoperatively, the patient's incisions were healed, and his sutures were removed. He was transitioned out of his splint into a pneumatic walker with heel wedges at 2 weeks. He was instructed to begin gentle ankle range of motion exercises, in line with the functional rehabilitation protocol described by Willets et al.. He was advanced to partial weight bearing in the CAM walker at 3 weeks and full weight bearing at 4 weeks. At 6 weeks postoperatively, the patient was sent to begin formal physical therapy, removed the heel wedges from the CAM walker, and transitioned to a sneaker by 8 weeks postoperatively.
By postoperative week 12, the patient's skin had completely healed, and he was ambulating without his pneumatic walker and was progressing well in physical therapy. He was walking up his stairs at home and felt a sudden pop in the back of his ankle at the surgical site. He had a wound in the prior surgical region and reported to an outside emergency department. He was found to have a transverse wound on his posterior ankle overlying the Achilles, perpendicular to his longitudinal surgical incision, with an associated rerupture of the Achilles tendon. The skin was repaired with suture at the emergency room, and the patient followed up in clinic several days later. At follow-up, it was noted that there was no continuity of the Achilles tendon with Thompson testing, and there was a palpable gap, along with a transverse laceration poorly reapproximated with serosanguinous drainage. The patient was indicated for irrigation and debridement with revision Achilles repair.
The patient was taken back to the operating room and placed in prone position. A 2 cm transverse laceration over his prior Achilles rupture site was noted, with an underlying rerupture of the Achilles tendon at the same level (Figure 2). The incision was extended medially and laterally, and dissection was carried down to the tendon. The suture tape was identified, with knots still intact, but the sutures had pulled out of the tendon proximally. The suture tape was removed, and the area copiously irrigated; no evidence of infection was noted. A percutaneous jig (Arthrex, Inc., Naples, FL) was utilized in accordance with the PARS  midsubstance Achilles repair technique through the open transverse laceration (Figure 3). Sutures from the proximal Achilles stump were passed through the distal tendon with a lasso and secured into the calcaneus using swivel lock anchors  (Arthrex, Inc., Naples, FL) with the ankle held in plantar flexion (Figure 4). The same functional rehabilitation protocol was used postoperatively.
At most recent follow-up, six months after revision surgery, the patient's skin is well healed, and he walks without a limp and has begun jogging again (Figure 5).