BACKGROUND The purpose of the study was to determine whether real-time intraoperative ultrasonography improved implant positioning and stump approximation in patients with acute Achilles tendon rupture managed percutaneously. METHODS The needles were introduced percutaneously without ultrasonography and their position was checked relative to cutaneous landmarks and by palpation. Then, intraoperative ultrasonography was performed to assess needle position at the proximal tendon segment, tendon tear, and distal tendon segment. Incorrectly placed needles were removed and reinserted under real-time ultrasonographic guidance. Tendon apposition was checked ultrasonographically. RESULTS We included 21 patients (19 males, two females) with unilateral acute Achilles tendon rupture, in whom 42 needles (one medial and one lateral) were inserted. Correct positioning was achieved without ultrasonographic guidance for 19 (45%) needles overall, 15 of 21 (71%) medial needles, and four of 21 (19%) lateral needles. The remaining 23 needles were correctly repositioned under ultrasonographic guidance. The correct positioning rates with and without ultrasonography differed significantly for all needles (p < 0.0001) and for lateral needles (p < 0.0001) but not for medial needles (p = 0.03). Intraoperative ultrasonography confirmed tendon stump approximation in all cases. CONCLUSIONS Without imaging, 55% of needles were correctly positioned. Intraoperative ultrasonography allowed correct positioning of all needles and provided intraoperative confirmation of stump approximation.