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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

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acute achilles tendon rupture

Acute Achilles Tendon Rupture

Paul Herickhoff, MD

March 26, 2009

background
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
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
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
Diagnosis
  • Weakness in plantarflexion
  • Gap in tendon
  • Positive Thompson test
imaging
Imaging
  • X-rays
    • Indicated if fracture or avulsion fracture suspected
  • Ultrasound or MRI
    • Reveal tendon degeneration, if present
treatment
Treatment
  • Non-operative versus operative treatment controversial
    • Several methods described for each
non operative
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
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%)
operative10
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
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 op12
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
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
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
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.