Updated: 4/8/2019

Achilles Tendon Rupture

Topic
Review Topic
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0
Questions
21
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Evidence
20
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Videos
8
Cases
2
Techniques
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https://upload.orthobullets.com/topic/7021/images/achilles key image.jpg
https://upload.orthobullets.com/topic/7021/images/picture 1 resting tension.jpg
https://upload.orthobullets.com/topic/7021/images/palpable gap.jpg
https://upload.orthobullets.com/topic/7021/images/radiograph.jpg
https://upload.orthobullets.com/topic/7021/images/ultrasound.jpg
https://upload.orthobullets.com/topic/7021/images/complete tear ultrasound.jpg
Introduction
  • Acute rupture of the achilles tendon
    • often misdiagnosed as an ankle sprain
    • may be missed in up to 25%
  • Epidemiology
    • incidence
      • 18:100,000 per year
    • demographics
      • more common in men
      • most common in ages 30-40
    • risk factors
      • episodic athletes, "weekend warrior"
      • flouroquinolone antibiotics
      • steroid injections
  • Mechanism
    • usually traumatic injury during a sporting event
    • may occur with
      • sudden forced plantar flexion
      • violent dorsiflexion in a plantar flexed foot
  • Pathoanatomy
    • rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region
Anatomy
  • Achilles tendon
    • largest tendon in body
    • formed by the confluence of
      • soleus muscle tendon 
      • medial and lateral gastrocnemius tendons 
    • blood supply from posterior tibial artery
Presentation
  • History
    • patient usually reports a "pop"
  • Symptoms
    • weakness and difficulty walking
    • pain in heel
  • Physical exam
    • inspection
      • increased resting ankle dorsiflexion in prone position with knees bent
      • calf atrophy may be apparent in chronic cases
    • palpation
      • palpable gap
    • motion
      • weakness to ankle plantar flexion
      • increased passive dorsiflexion
    • provocative test
      • Thompson test
        • lack of plantar flexion when calf is squeezed
Imaging
  • Radiographs
    • indications
      • used to rule out other pathology
  • Ultrasound
    • indications
      • may be useful to determine complete vs. partial ruptures
  • MRI
    • indications
      • equivocal physical exam findings
      • chronic ruptures
    • findings
      • will show acute rupture with retracted tendon edges
Treatment
  • Nonoperative
    • functional bracing/casting in resting equinus
      • indications
        • acute injuries with surgeon or patient preference for non-operative management
        • sedentary patient
        • medically frail patients
      • outcomes
        • equivalent plantar flexion strength compared to operative management
        • increased risk of re-rupture compared to operative management
          • new studies show that this may not be significant if functional rehabilitation used 
        • fewer complications compared to operative treatment
  • Operative
    • open end-to-end achilles tendon repair 
      • indications
        • acute ruptures (approximately <6 weeks)
      • outcomes
        • decreased rate of re-rupture compared to non-operative management
          • new Level 1 evidence has suggested no difference in re-rupture rates with functional rehab protocol
        • no significant difference in plantar flexion strength with functional rehab protocol
    • percutaneous Achilles tendon repair
      • indications
        • concerns over cosmesis of traditional scar
      • outcomes
        • higher risk of sural nerve damage
        • lesser risk of wound complications/infection compared with open repair
    • reconstruction with VY advancement    
      • indications
        • chronic ruptures with defect < 3cm
    • flexor hallucis longus transfer +/- VY advancement of gastrocnemius      
      • indications
        • chronic ruptures with defect > 3cm
        • requires a functioning tibial nerve 
Surgical Techniques
  • Functional bracing/casting in resting equinus
    • technique
      • cast/brace in 20 degrees of plantar flexion
      • early functional rehab for those treated without a cast
  • End-to-end achilles tendon repair
    • approach
      • make incision just medial to achilles tendon to avoid sural nerve
    • technique
      • incise paratenon
      • expose tendon edges
      • repair with heavy non-absorbable suture
    • postoperative care
      • immobilize in 20° of plantar flexion to decrease tension on skin and protect tendon repair for 4-6 weeks
  • Percutaneous achilles tendon repair
    • technique
  • Reconstruction with VY advancement
    • technique
      • make V cut with apex at musculotendinous junction with limbs divergent to exit the tendon
      • V is incised through only the superficial tendinous portion leaving the muscle fibers intact
  • Flexor hallucis longus transfer ± VY advancement of gastrocnemius
    • technique
      • excise degenerative tendon edges
      • release FHL tendon at the Knot of Henry and transfer through the calcaneus
      • residual hallux plantarflexion weakness  
Complications
  • Re-rupture
    • incidence
      • higher with non-operative management (~10-40% vs 2%)
        • new Level 1 evidence has shown no difference in re-rupture rates
    • treatment
      • surgical repair
  • Wound healing complications
    • incidence
      • 5-10%
    • risk factors
      • smoking (most common)
      • female gender
      • steroid use
      • open technique (versus percutaneous)  
    • treatment
      • deep infection
        • debridement of necrotic/infected Achilles tendon
        • culture-specific antibiotics for 6 weeks
  • Sural nerve injury
    • incidence
      • higher when percutaneous approach is used
 

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Technique Guides (1)
Questions (21)
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(OBQ13.146) A 58-year-old male with a history of chronic posterior ankle pain feels a "pop" and experiences a sharp pain in the back of his heel after jumping off a step. He is placed in a splint and is subsequently lost to follow-up. Six months later he presents complaining of weakness and pain. Examination reveals weakness to ankle plantarflexion and increased passive ankle dorsiflexion. An MRI of his ankle is shown in Figure A. Intraoperatively, a tendon defect a is measured to be 4cm in length. What is the most appropriate treatment plan: Review Topic

QID: 4781
FIGURES:
1

Equinus casting for 6 to 8 weeks

1%

(35/3244)

2

Surgical repair through an percutaneous approach with plantaris transfer

1%

(31/3244)

3

Surgical reconstruction through an open approach with Achilles allograft

19%

(631/3244)

4

Surgical repair through an open approach with flexor hallucis longus transfer

77%

(2484/3244)

5

Surgical repair through an limited open approach with peroneus longus transfer

1%

(33/3244)

ML 3

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(OBQ13.51) Which of the following outcomes has been reported with surgical repair of acute Achilles tendon ruptures as compared to non-operative treatment with functional rehabilitation? Review Topic

QID: 4686
1

Improved ankle dorsiflexion strength at 6 month follow-up

3%

(115/4470)

2

Improved ankle dorsiflexion range-of-motion at 6 month follow-up

1%

(63/4470)

3

Improved mean SMFA scores at 12 months

1%

(62/4470)

4

A statistically significant decrease in re-rupture rates

26%

(1146/4470)

5

Increased complication rates

68%

(3056/4470)

ML 4

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(OBQ12.36) A 36-year-old man presents with fever, pain, and wound drainage 4 months after repair of an acute Achilles tendon rupture. A clinical image is shown in Figure A. Laboratory studies show an ESR of 29 (reference range 0-22 mm/hr). It is decided that he will undergo debridement and irrigation followed by culture specific antibiotic therapy. In the operating room, the Achilles tendon is found to have re-ruptured with a 5 cm defect. What is the most appropriate surgical treatment at this time? Review Topic

QID: 4396
FIGURES:
1

Primary repair of the re-ruptured Achilles tendon

1%

(31/3875)

2

Debridement of necrotic and infected tendon tissue, with no attempt at reconstruction

77%

(3003/3875)

3

V-Y plasty of the re-ruptured Achilles tendon

3%

(115/3875)

4

Repair of the re-ruptured Achilles tendon with a turndown procedure

4%

(149/3875)

5

Repair of defect with flexor hallucis longus tendon transfer

14%

(546/3875)

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(OBQ10.36) A 58-year-old golfer fell stepping into a sand trap and ruptured his Achilles tendon one year ago. He initially chose non-operative treatment, but became unsatisfied with a tender fullness behind his ankle and ankle weakness noticeable during his tee shots. At the time of surgery, a large disorganized fibrous mass is found at the site of rupture. Following extensive debridement there is a 5 cm gap between viable tissue ends. Which of the following surgical techniques provides the greatest likelihood of a successful clinical outcome? Review Topic

QID: 3124
1

Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon

5%

(124/2455)

2

Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus

3%

(68/2455)

3

Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus

84%

(2067/2455)

4

Reconstruction with hamstring autograft

7%

(163/2455)

5

Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program

1%

(24/2455)

ML 1

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(OBQ08.269) What is the greatest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks? Review Topic

QID: 655
1

Lower rate of infection

1%

(14/2356)

2

Higher rate of normal skin sensation

1%

(13/2356)

3

Better skin cosmesis

1%

(29/2356)

4

Lower rate of dehiscence

1%

(16/2356)

5

Lower rate of re-rupture

97%

(2278/2356)

ML 1

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(OBQ07.54) A 38-year-old patient has an acute Achilles tendon rupture. He is active in sports and is deciding between operative and nonoperative treatments. Which of the following statements applies to patients undergoing conservative treatment with a cast for 6 weeks followed by a course of physical therapy? Review Topic

QID: 715
1

They have lower patient satisfaction scores

3%

(51/1483)

2

They are less likely to return to sport

4%

(53/1483)

3

Their ultimate strength is decreased

11%

(170/1483)

4

They have a higher risk for rerupture

80%

(1181/1483)

5

They have a higher risk of skin problems

1%

(22/1483)

ML 1

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(OBQ06.270) Which factor increases the chance of wound complications after Achilles tendon repair? Review Topic

QID: 281
1

Increased body mass index

4%

(67/1516)

2

Immediate surgery

2%

(26/1516)

3

Male gender

0%

(7/1516)

4

Age over 40 years old

1%

(15/1516)

5

Tobacco use

92%

(1396/1516)

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(OBQ04.136) A 41-year-old female feels a pop in her ankle while playing tennis. She is diagnosed with an acute Achilles tendon rupture and elects to undergo nonoperative management. Which of the following is a difference seen with nonoperative management with early functional rehabilitation compared with operative treatment? Review Topic

QID: 1241
1

decreased incidence of deep venous thrombosis

9%

(111/1195)

2

no significant differences

44%

(529/1195)

3

increased rate of re-rupture

20%

(243/1195)

4

earlier return to sport

14%

(162/1195)

5

increased complication rate

12%

(140/1195)

ML 4

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