Acute Achilles Tendon RupturePaul Herickhoff, MDMarch 26, 2009

BackgroundLargest, most powerful tendon in bodyFormed by gastrocnemius and soleusIncidence of rupture 18:100,000Incidence is increasingAs demonstrated by population based studies in Finland, Canada, Scotland and Sweden

PresentationAdults 40-50 y.o. primarily affected (M>F)Athletic activities, usually with sudden starting or stoppingSnap in heel with pain, which may subside quickly

Factors to consider25% of patients have previous symptoms of Achilles inflammationLeppilahti et al. Clin Orthop 1998Associated conditions:OchronosisSteroid useQuinolonesInflammatory arthritis

DiagnosisWeakness in plantarflexionGap in tendonPositive Thompson test

ImagingX-raysIndicated if fracture or avulsion fracture suspectedUltrasound or MRIReveal tendon degeneration, if present

TreatmentNon-operative versus operative treatment controversialSeveral methods described for each

Non-operativeCast immobilizationTraditional recommendation is 8 weeks of immobilizationWallace recommended patellar tendon bearing orthosis for weeks 4-8Functional brace with semi-rigid tape and polypropylene orthoses for duration of treatment also describedRerupture rate 8-39% reported

OperativeOpen repairLocking stitch, +/- augmentation with plantaris or meshPost-op care = Casting for 6-8 weeksRisks: Infection (4-21%), Rerupture (1-5%)

OperativePercutaneousBunnell stitchWeaker than open repair (Rerupture 0-17%)Risk of sural nerve injury (0-13%)Decreased infection risk

Op vs. Non-opWong et al Am J Sports Med 2002Metanalysis 125 articles, 5370 patientsWound 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-opBhandari et al. Clin Orthop 2002More stringent inclusion criteria than Wong6 studies, 448 patientsWound infection (5% vs 0%)Rerupture (3% vs 13%)

Risk Factors for Wound ComplicationBruggeman et al Clin Orthop 2004 and Pajala et al. JBJS 2002AgeTobaccoDiabetesFemale genderSteroid useTreatment delayLow energy injury (during ADLs)

SummaryIncidence of Achilles tendon rupture increasingOperative repair associated with lower rerupture rate, but higher wound complication rate compared to non-opPercutaneous repair has risk of nerve injuryReview risk factors before deciding treatment plan

ReferencesBhandari, 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, 2004Chiodo, CP and MG Wilson. Current Concepts Review: Acute Ruptures of the Achilles Tendon. Foot Ank Int 27:305-13, 2006Leppilahti 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.