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 18:100,000 –Incidence is increasing As demonstrated by population based studies in Finland, Canada, Scotland and Sweden

3. Presentation Adults 40-50 y.o. primarily affected (M>F) 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 ADL’s)

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 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.