Open Traumatic Achilles tendon Rupture in a Pediatric Patient Managed by Modified Kessler Technique: A Case Report

Introduction

Achilles tendon rupture is among the most common tendon injuries encountered in orthopedic practice. However, the vast majority of reported cases involve closed spontaneous or degenerative ruptures in middle-aged recreational athletes, typically males in the fourth to fifth decade of life ^[1]. Open traumatic Achilles tendon ruptures secondary to sharp penetrating objects are much less commonly reported, carrying the added risks of wound contamination, tendon exposure, and concurrent injury to adjacent neurovascular structures.

In the pediatric population, Achilles tendon ruptures of any etiology are relatively uncommon. The pediatric Achilles tendon is characteristically more elastic and resilient than its adult counterpart, with the calcaneal apophysis – rather than the tendon itself – being the weakest link in the musculotendinous unit during childhood ^[2]. Consequently, avulsion injuries at the calcaneal apophysis are more frequently reported in children ^[3]. Open traumatic ruptures in children have very limited published literature ^[4].

To identify relevant literature, we searched PubMed/MEDLINE and Google Scholar using combinations of terms including “Achilles tendon rupture,” “pediatric,” “adolescent,” “tendon repair,” and “imaging.” Relevant case reports, reviews, epidemiological studies, and biomechanical studies were reviewed, and reference lists of relevant articles were also screened for additional studies.

The Achilles tendon is anatomically flanked by neurovascular bundles medially, which are vulnerable in sharp lacerating injuries of the posterior ankle region. Failure to recognize and manage concurrent neurovascular injury in conjunction with tendon repair may result in chronic sensory deficits, ischemic complications, and suboptimal functional recovery.

A focused review of the published literature shows that very few cases of open Achilles tendon rupture in the pediatric age group have been reported. Reporting the management and outcomes of such cases may help clinicians managing similar injuries ^{[5, 6, 7]}.

The modified Kessler technique, originally developed for flexor tendon repair in the hand, has been widely adopted for Achilles tendon reconstruction because it provides good repair strength with less gap formation compared to simpler suture configurations ^[8]. We present this case to describe our experience with primary modified Kessler repair in an open pediatric Achilles tendon rupture (Table 1).

Case Report

Discussion

This case is unusual because of the patient’s age, open injury pattern. First, it represents a rare occurrence of complete open Achilles tendon rupture in a 9-year-old child. Second, it demonstrates that with prompt surgical management, excellent functional outcomes (AOFAS score 95) including full return to childhood physical activity are achievable.

Achilles tendon rupture is less common in children. Unlike adults, where degeneration and eccentric loading predispose the tendon to failure, the pediatric Achilles tendon retains high elasticity and intrinsic tensile strength. The weakest point in the pediatric posterior chain is the calcaneal apophysis – leading to Sever’s disease or apophyseal avulsions rather than midsubstance tendon failure ^[2]. In open injuries, however, sharp lacerating injuries can still result in complete tendon transection.

The diagnosis of complete Achilles tendon rupture was established clinically by a positive Thompson test and confirmed by preoperative ultrasonography. Ultrasonography is the first-line imaging modality of choice for Achilles tendon injuries – it is rapid, cost-effective, dynamic, and avoids ionizing radiation, which is particularly pertinent in the pediatric population ^[9]. Magnetic resonance imaging, though more detailed, was not required in this acute setting given the clear clinical and sonographic diagnosis. Plain radiography was performed to exclude bony injury and avulsion fractures at the calcaneal apophysis, which are more common in children ^[3] (Figs. 5 and 6).

The neurovascular bundle lies in close proximity to the Achilles tendon and is particularly vulnerable in posterior ankle lacerations.

The posterior tibial vessels, which course medially to the Achilles tendon, showed adventitial contusion without frank arterial injury in our case. Vascular integrity was confirmed intraoperatively. Had there been a complete vascular transection, immediate vascular surgical intervention would have been required to prevent limb ischemia. In surgeons managing such injuries, vascular assessment should be performed when vascular injury is suspected.

Regarding tendon repair, the modified Kessler technique has been studied in biomechanical models. Hockenbury and Johns (1990) demonstrated superior tensile load-to-failure and minimal gap formation with Kessler-based repairs compared to Bunnell or simple suture configurations in cadaveric Achilles tendons ^[8]. Compared with the Krackow technique, the modified Kessler repair provides adequate tensile strength with smaller suture bulk, making it particularly suitable for the pediatric population ^[10]. In our case, suture caliber and bite size were adjusted proportionally to account for the smaller tendon diameter, to avoid damage to the smaller tendon.

The post-operative rehabilitation protocol used in this case followed a progressive plantar-flexion reduction and early functional mobilization model. Careful wound management was important in this case because of contamination risk. Pediatric skin is more pliable and vascular than adult skin, facilitating wound healing; however, contaminated wounds still carry infection risk. Our protocol of copious irrigation, conservative debridement, layered primary closure, and targeted antibiotic prophylaxis resulted in uneventful wound healing with no infective complications. Post-operative recovery was uneventful, with normal walking and return to activities by 6 months after surgery with an AOFAS ankle-hindfoot score of 95, indicating excellent functional recovery. A limitation of this report is the relatively short follow-up duration; however, early functional recovery was excellent.

In summary, this case demonstrates that early repair of open Achilles tendon injury in children can result in good functional recovery.

Conclusion

Open traumatic Achilles tendon rupture, though uncommon in children, demands prompt recognition and surgical management. Primary Achilles tendon repair using the modified Kessler technique, combined with intra-operative neurovascular assessment, wound irrigation, and structured progressive rehabilitation, results in excellent functional outcomes. Compared with the Krackow technique, the modified Kessler repair provides adequate tensile strength with smaller suture bulk, making it particularly suitable for the pediatric population.

In this 9-year-old patient, full plantar flexion strength, complete return to physical activity were achieved by 6 month follow-up. This case adds to the limited pediatric literature on open Achilles tendon injuries and highlights the importance of clinician awareness of this rare but serious injury pattern.

Clinical Message

Early primary repair with the modified Kessler technique gives a strong, low-bulk construct well suited to the small pediatric tendon, and with structured rehabilitation a full return to activity is a realistic goal.

References

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About the Authors

• 

  Mubasshir Farooqui

• 

  Nikhil Game