Achilles Tendon Repair
Acute complete midsubstance rupture of the [right / left] Achilles tendon
Same
Open primary repair of acute [right / left] midsubstance Achilles tendon rupture
[***, MD/DO]
[Resident/Fellow/PA name]
[General / Regional with general / Regional with monitored anesthesia care]
The patient is a [age]-year-old [male / female] who sustained an acute [right / left] Achilles tendon rupture during [mechanism]. Examination demonstrated a palpable midsubstance defect and diminished plantarflexion with calf squeeze. Operative and nonoperative treatment, anticipated rehabilitation, risks, benefits, and alternatives were discussed. The patient elected operative repair, and informed consent was obtained.
A complete midsubstance rupture was present approximately [***] cm proximal to the calcaneal insertion. The tear was [transverse / oblique / frayed] with a gap of [***] cm at rest. The tendon ends were [healthy / frayed] and suitable for primary repair. The calcaneal insertion was intact. The paratenon was suitable for closure. The sural nerve was [not encountered / identified and protected].
After anesthesia was established, the patient was positioned prone with all pressure points padded. The operative leg was supported so the ankle moved freely, and the opposite ankle remained available for tension comparison. A [thigh / calf] tourniquet was applied. The [right / left] lower extremity was prepared and draped in sterile fashion. A surgical time-out confirmed the patient, procedure, and side. Preincision antibiotics were administered. The tourniquet was inflated to [pressure] mmHg for [duration] minutes.
A posteromedial longitudinal incision was made adjacent to the rupture. Full-thickness flaps were developed with limited undermining. The paratenon was opened longitudinally and preserved for closure. The sural nerve was [not encountered / identified and protected]. The rupture hematoma was evacuated, and nonviable or severely frayed fibers were excised while preserving tendon length.
A [Krackow locking-loop / modified Kessler] core stitch using [suture] was placed in each tendon stump. With the ankle plantarflexed, the tendon ends were apposed and the sutures were tied, restoring resting tension comparable with the opposite side. [A circumferential epitendinous repair was added with [suture]. / No additional epitendinous stitch was used.]
Calf compression produced plantarflexion, and the repair remained well apposed without visible gapping. The wound was irrigated. The tourniquet was released, and hemostasis was confirmed.
The paratenon was closed over the repair with [suture], followed by layered subcutaneous and skin closure. A sterile dressing was applied. The leg was placed in a [posterior splint / short-leg cast / controlled ankle-motion boot with heel wedges] with the ankle in plantarflexion. All counts were correct. The patient tolerated the procedure and was transferred to PACU in stable condition.
None
[None / Debrided Achilles tendon tissue to pathology / ***]
[*** mL]
[None / ***]
The patient was transferred to [PACU / inpatient unit] in stable condition. The postoperative plan is [non-weight-bearing / protected weight-bearing / weight-bearing as tolerated] in [splint / cast / boot] with dorsiflexion limited to [position] until [time or milestone]. The planned wound review is [timing], and the rehabilitation protocol will begin [timing or milestone]. Venous-thromboembolism prophylaxis is [mechanical / medication and duration / none based on documented risk assessment].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Acute complete midsubstance rupture of the [right / left] Achilles tendon
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Open primary repair of acute [right / left] midsubstance Achilles tendon rupture
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / Regional with general / Regional with monitored anesthesia care]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX who sustained an acute [right / left] Achilles rupture during [mechanism]. Examination demonstrated a palpable midsubstance defect and diminished plantarflexion with calf squeeze. Operative and nonoperative treatment, rehabilitation, risks, benefits, and alternatives were discussed. The patient elected operative repair, and informed consent was obtained.
FINDINGS: Complete midsubstance rupture approximately *** cm proximal to the calcaneal insertion. The tear was [transverse / oblique / frayed] with a gap of *** cm at rest. The tendon ends were [healthy / frayed] and suitable for primary repair. The calcaneal insertion was intact, and the paratenon was suitable for closure. The sural nerve was [not encountered / identified and protected].
DESCRIPTION OF PROCEDURE:
After anesthesia, the patient was positioned prone with all pressure points padded. The operative leg moved freely, and the opposite ankle remained available for tension comparison. The extremity was prepared and draped sterilely. A time-out confirmed the patient, procedure, and side. Antibiotics were administered. A [thigh / calf] tourniquet was inflated to *** mmHg for *** minutes.
A posteromedial incision was made adjacent to the rupture. Full-thickness flaps were developed with limited undermining. The paratenon was opened longitudinally and preserved. The sural nerve was [not encountered / identified and protected]. The hematoma was evacuated, and nonviable or severely frayed tendon was excised while preserving viable length.
A [Krackow / modified Kessler] core stitch using [suture] was placed in each stump. With the ankle plantarflexed, the tendon ends were apposed and the sutures tied. Resting tension matched the opposite side. [A circumferential epitendinous repair was added with [suture]. / No additional epitendinous stitch was used.]
Calf compression produced plantarflexion, and the repair remained well apposed without visible gapping. The wound was irrigated. The tourniquet was released, and hemostasis was confirmed. The paratenon was closed with [suture], followed by layered subcutaneous and skin closure. A sterile dressing was applied, and the leg was immobilized in a [posterior splint / short-leg cast / controlled ankle-motion boot with heel wedges] in plantarflexion. All counts were correct. The patient tolerated the procedure and was transferred to PACU in stable condition.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [None / ***]
COMPLICATIONS: None
DRAINS: [None / ***]
DISPOSITION: PACU in stable condition; [weight-bearing, immobilization, rehabilitation, and thromboprophylaxis plan]
Signed: .ME, .MYDEGREE
.TODAYVariants
Minimally invasive or percutaneous acute repair
Document the named device or technique, rupture localization, incision or portal number and locations, and whether the tendon ends or paratenon were directly visualized. State how the sural nerve was localized or protected, the proximal and distal suture paths and tendon purchase, how the sutures were retrieved and tied, and how tendon apposition was confirmed. Record the repaired resting angle against the opposite side, the calf-squeeze response, any assessment for gapping, closure of each incision, and the final immobilization position.
Charting Tips
- Record the injury mechanism, examination findings, and imaging findings when imaging was obtained.
- State the rupture location, tear pattern, gap at a stated ankle position, tendon quality, and whether primary apposition was possible.
- Identify the approach, paratenon handling, and whether the sural nerve was encountered and protected.
- Document the core-suture configuration and material, final tension compared with the opposite side, and calf-squeeze response.
- If graft or biologic material was used, identify its source and purpose; do not imply augmentation during a primary end-to-end repair.
- Record tourniquet use, immobilization, weight-bearing status, rehabilitation timing, wound follow-up, and venous-thromboembolism plan.
Documentation & Reimbursement Considerations
- Report Achilles Tendon Repair as the primary service when it is the definitive operation performed.
- Open and percutaneous approaches to a primary acute Achilles repair fall within the same general reporting category. Document the approach and technique actually used.
- Primary repair without graft tissue, primary repair requiring a graft, and delayed or secondary reconstruction are distinct categories. State whether graft tissue was used, its source, and how it contributed to the repair.
- These Achilles repair services generally carry a 90-day Medicare global period.
- Routine core suturing, epitendinous reinforcement, paratenon closure, and immobilization are components of the documented repair rather than unrelated additional services.