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 semirigid 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 (421%), Rerupture (15%)

Operative
Percutaneous
Bunnell stitch Weaker than open repair (Rerupture 017%) 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 ADLs)

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.