Acute Achilles Tendon Rupture

Paul Herickhoff, MD

March 26, 2009

Background

• Largest, most powerful tendon in body

• Formed by gastrocnemius and soleus

• Incidence of rupture 18:100,000– Incidence is increasing

• As demonstrated by population based studies in Finland, Canada, Scotland and Sweden

Presentation

• Adults 40-50 y.o. primarily affected (M>F)

• Athletic activities, usually with sudden starting or stopping

• “Snap” in heel with pain, which may subside quickly

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

Diagnosis

• Weakness in plantarflexion

• Gap in tendon

• Positive Thompson test

Imaging

• X-rays– Indicated if fracture or

avulsion fracture suspected

• Ultrasound or MRI– Reveal tendon

degeneration, if present

Treatment

• Non-operative versus operative treatment controversial– Several methods

described for each

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

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%)

Operative

• Percutaneous– Bunnell stitch– Weaker than open

repair (Rerupture 0-17%)

– Risk of sural nerve injury (0-13%)

– Decreased infection risk

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

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%)

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 ADL’s)

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

References• Bhandari, M et al. “Treatment of Achilles tendon ruptures: a

systematic overview and metaanalysis.” Clin Orthop 400:190-200, 2002.

• Bruggeman, NB et al. “Wound complications after open Achilles tendon repair: an analysis of risk factors.” Clin Orthop 427:63-66, 2004

• Chiodo, CP and MG Wilson. “Current Concepts Review: Acute Ruptures of the Achilles Tendon.” Foot Ank Int 27:305-13, 2006

• Leppilahti J et al. “Outcome and prognostic factors of Achilles rupture using a new scoring method. Clin Orthop 346:152-61, 2001.

• Pajala, A et al. “Rerupture and deep infection following treatment of total Achilles rupture.” JBJS 84-A:2016-21, 2002.

• Wong, J et al. “Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J. Sports Med. 30:565-75, 2002.