Updated: 6/7/2021

Achilles Tendon Rupture

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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
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https://upload.orthobullets.com/topic/7021/images/complete tear ultrasound.jpg
  • summary
    • Achilles Tendon Ruptures are common tendon injuries that occur due to sudden dorsiflexion of a plantarflexed foot, most commonly associated with sporting events. 
    • Diagnosis can be made clinically with weakness of plantarflexion with a positive Thompson's test. MRI studies may be indicated for surgical management of chronic injuries. 
    • Treatment may be nonoperative or operative depending on patient age, patient activity demands and chronicity of injury.
  • Epidemiology
    • Incidence
      • 18:100,000 per year
        • may be missed in up to 25%
    • Demographics
      • more common in men
      • most common in ages 30-40
    • Risk factors
      • episodic athletes, "weekend warrior"
      • flouroquinolone antibiotics
      • steroid injections
  • Etiology
    • 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
            • decreased risk of re-rupture after surgical repair when early ROM protocol used
      • 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
  • 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 (22)
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(OBQ17.192) A 28-year-old male laborer suffered a left ankle injury 4 months ago at work while unloading a dolly. He notes difficulty walking and pain with ambulating. Physical exam shows an inability to toe walk on the left, as well as the finding demonstrated in Figure 1. What other test will be positive and which procedure will likely best result in the restoration of power and function?

QID: 210279
FIGURES:
1

Thompson test, primary repair with synthetic graft augmentation

6%

(93/1595)

2

Thomas test, VY advancement

5%

(75/1595)

3

Thompson test, VY advancement with tendon transfer

86%

(1365/1595)

4

Thessaly test, VY advancement with tendon transfer

1%

(14/1595)

5

Thompson test, debridement of osseous spur and primary repair

2%

(34/1595)

L 1 A

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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:

QID: 4781
FIGURES:
1

Equinus casting for 6 to 8 weeks

1%

(44/4136)

2

Surgical repair through an percutaneous approach with plantaris transfer

1%

(37/4136)

3

Surgical reconstruction through an open approach with Achilles allograft

18%

(760/4136)

4

Surgical repair through an open approach with flexor hallucis longus transfer

78%

(3223/4136)

5

Surgical repair through an limited open approach with peroneus longus transfer

1%

(37/4136)

L 3 A

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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?

QID: 4686
1

Improved ankle dorsiflexion strength at 6 month follow-up

3%

(136/5098)

2

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

1%

(76/5098)

3

Improved mean SMFA scores at 12 months

1%

(76/5098)

4

A statistically significant decrease in re-rupture rates

25%

(1294/5098)

5

Increased complication rates

68%

(3485/5098)

L 4 B

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(SBQ12FA.34) A 55-year-old man has a chronic Achilles tendon rupture. He is scheduled for surgical reconstruction using V-Y advancement of the gastrocnemius-soleus complex aponeurosis with augmentation using a local tendon transfer. What is the native insertion and nerve that innervates the tendon most commonly used to augment this procedure?

QID: 3841
1

1st digit proximal phalanx, Tibial nerve

12%

(195/1626)

2

1st digit distal phalanx, Superficial peroneal nerve

3%

(43/1626)

3

Base of the 5th metatarsal, Superficial peroneal nerve

4%

(62/1626)

4

1st cuneiform and 1st metatarsal, Deep peroneal nerve

4%

(62/1626)

5

1st digit distal phalanx, Tibial nerve

77%

(1247/1626)

L 2 C

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(SBQ12FA.20) What would be the most appropriate treatment for the sub-acute injury seen in Figures A-C?

QID: 3827
FIGURES:
1

End-to-end repair

4%

(151/3656)

2

Carbon fiber composites synthetic graft

0%

(18/3656)

3

Achilles tendon xenograft with medial and lateral aponeurotic fascial turndown flaps

4%

(160/3656)

4

Posterior tibialis tendon transfer with medial and lateral aponeurotic fascial turndown flaps

3%

(109/3656)

5

Flexor hallucis longus tendon transfer with sliding V-Y advancement of the gastrocnemius-soleus complex aponeurosis

87%

(3192/3656)

L 1 A

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(SBQ12FA.76) A 56-year old male presents 4 months after injuring his ankle when he misstepped off a curb. Figures A and B are sagittal and coronal MR images taken recently. He undergoes surgery and intra-operatively the surgeon elects to perform a tendon transfer to augment the repair. What deficit would be expected following a transfer of the most common tendon used in this scenario?

QID: 3883
FIGURES:
1

Weakness on resisted foot eversion

6%

(152/2356)

2

Weakness on resisted hallux plantarflexion

78%

(1846/2356)

3

Weakness on resisted hallux dorsiflexion

6%

(136/2356)

4

Weakness on resisted ankle inversion

6%

(130/2356)

5

Weakness on resisted ankle dorsiflexion

3%

(75/2356)

L 2 C

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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?

QID: 4396
FIGURES:
1

Primary repair of the re-ruptured Achilles tendon

1%

(35/4398)

2

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

78%

(3410/4398)

3

V-Y plasty of the re-ruptured Achilles tendon

3%

(136/4398)

4

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

4%

(162/4398)

5

Repair of defect with flexor hallucis longus tendon transfer

14%

(620/4398)

L 2 B

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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?

QID: 3124
1

Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon

5%

(145/2863)

2

Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus

3%

(75/2863)

3

Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus

85%

(2428/2863)

4

Reconstruction with hamstring autograft

6%

(172/2863)

5

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

1%

(27/2863)

L 1 A

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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?

QID: 655
1

Lower rate of infection

1%

(15/2780)

2

Higher rate of normal skin sensation

1%

(14/2780)

3

Better skin cosmesis

1%

(39/2780)

4

Lower rate of dehiscence

1%

(18/2780)

5

Lower rate of re-rupture

97%

(2686/2780)

L 2 C

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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?

QID: 715
1

They have lower patient satisfaction scores

4%

(68/1891)

2

They are less likely to return to sport

4%

(70/1891)

3

Their ultimate strength is decreased

12%

(222/1891)

4

They have a higher risk for rerupture

79%

(1486/1891)

5

They have a higher risk of skin problems

2%

(38/1891)

L 1 D

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

QID: 281
1

Increased body mass index

4%

(80/1978)

2

Immediate surgery

1%

(27/1978)

3

Male gender

0%

(9/1978)

4

Age over 40 years old

1%

(17/1978)

5

Tobacco use

93%

(1839/1978)

L 1 D

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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?

QID: 1241
1

Decreased incidence of deep venous thrombosis

8%

(119/1529)

2

No significant difference in functional outcomes

47%

(715/1529)

3

Increased rate of re-rupture

24%

(371/1529)

4

Earlier return to sport

11%

(169/1529)

5

Increased rate of complications

9%

(143/1529)

L 4 D

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