Acute Achilles Tendon Rupture

1
Acute Achilles Tendon Rupture

• Paul Herickhoff, MD
• March 26, 2009

2
Background

• Largest, most powerful tendon in body
• Formed by gastrocnemius and soleus
• Incidence of rupture 18100,000
• Incidence is increasing
• As demonstrated by population based studies in
  Finland, Canada, Scotland and Sweden

3
Presentation

• Adults 40-50 y.o. primarily affected (MgtF)
• Athletic activities, usually with sudden starting
  or stopping
• Snap in heel with pain, which may subside
  quickly

4
Factors to consider

• 25 of patients have previous symptoms of
  Achilles inflammation
• Leppilahti et al. Clin Orthop 1998
• Associated conditions
• Ochronosis
• Steroid use
• Quinolones
• Inflammatory arthritis

5
Diagnosis

• Weakness in plantarflexion
• Gap in tendon
• Positive Thompson test

6
Imaging

• X-rays
• Indicated if fracture or avulsion fracture
  suspected
• Ultrasound or MRI
• Reveal tendon degeneration, if present

7
Treatment

• Non-operative versus operative treatment
  controversial
• Several methods described for each

8
Non-operative

• Cast immobilization
• Traditional recommendation is 8 weeks of
  immobilization
• Wallace recommended patellar tendon bearing
  orthosis for weeks 4-8
• Functional brace with semi-rigid tape and
  polypropylene orthoses for duration of treatment
  also described
• Rerupture rate 8-39 reported

9
Operative

• Open repair
• Locking stitch, /- augmentation with plantaris
  or mesh
• Post-op care Casting for 6-8 weeks
• Risks Infection (4-21), Rerupture (1-5)

10
Operative

• Percutaneous
• Bunnell stitch
• Weaker than open repair (Rerupture 0-17)
• Risk of sural nerve injury (0-13)
• Decreased infection risk

11
Op vs. Non-op

• Wong et al Am J Sports Med 2002
• Metanalysis 125 articles, 5370 patients
• Wound complication (14.6 vs 0.5)
• Rerupture (1.5 perc,1.4 open vs 10.7)
• Complication rates lowest in open repair and
  early mobilization, highest in percutaneous
  repair and early mobilization

12
Op vs. Non-op

• Bhandari et al. Clin Orthop 2002
• More stringent inclusion criteria than Wong
• 6 studies, 448 patients
• Wound infection (5 vs 0)
• Rerupture (3 vs 13)

13
Risk Factors for Wound Complication

• Bruggeman et al Clin Orthop 2004 and Pajala et
  al. JBJS 2002
• Age
• Tobacco
• Diabetes
• Female gender
• Steroid use
• Treatment delay
• Low energy injury (during ADLs)

14
Summary

• Incidence of Achilles tendon rupture increasing
• Operative repair associated with lower rerupture
  rate, but higher wound complication rate compared
  to non-op
• Percutaneous repair has risk of nerve injury
• Review risk factors before deciding treatment plan

15
References

• Bhandari, M et al. Treatment of Achilles tendon
  ruptures a systematic overview and
  metaanalysis. Clin Orthop 400190-200, 2002.
• Bruggeman, NB et al. Wound complications after
  open Achilles tendon repair an analysis of risk
  factors. Clin Orthop 42763-66, 2004
• Chiodo, CP and MG Wilson. Current Concepts
  Review Acute Ruptures of the Achilles Tendon.
  Foot Ank Int 27305-13, 2006
• Leppilahti J et al. Outcome and prognostic
  factors of Achilles rupture using a new scoring
  method. Clin Orthop 346152-61, 2001.
• Pajala, A et al. Rerupture and deep infection
  following treatment of total Achilles rupture.
  JBJS 84-A2016-21, 2002.
• Wong, J et al. Quantitative review of operative
  and nonoperative management of Achilles tendon
  ruptures. Am J. Sports Med. 30565-75, 2002.