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 new studies show equivalent rates of re-rupture if functional rehabilitation used versus operative repair 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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Percutaneous Achilles Tendon Repair Orthobullets Team Foot & Ankle - Achilles Tendon Rupture
QUESTIONS 1 of 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ19.131) You are reviewing the MRI in Figure A as part of an achilles tendon repair case preparation with your intern. Which of the following structures (A-E) indicates the sural nerve? QID: 214033 FIGURES: A Type & Select Correct Answer 1 A 1% (12/1443) 2 B 3% (44/1443) 3 C 4% (64/1443) 4 D 89% (1282/1443) 5 E 3% (38/1443) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.27) A 35-year-old patient presents with right calf weakness of approximately six weeks duration. The patient noted a pop in the back of their heel when carrying a heavy box up a flight of stairs. In the office, there is an approximately 3 cm palpable defect in the posterior heel cord. When examined in the prone position the foot rests in greater dorsiflexion compared to the contralateral. Which procedure will most likely need to be performed at the time of surgical repair? QID: 212923 Type & Select Correct Answer 1 Flexor digitorum longus transfer (FDL) 20% (410/2041) 2 Tibialis posterior transfer 1% (23/2041) 3 V-Y advancement of the achilles 73% (1491/2041) 4 Synthetic graft augmentation 4% (84/2041) 5 Peroneal brevis tendon transfer 1% (14/2041) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 Thompson test, primary repair with synthetic graft augmentation 6% (123/1954) 2 Thomas test, VY advancement 4% (87/1954) 3 Thompson test, VY advancement with tendon transfer 85% (1668/1954) 4 Thessaly test, VY advancement with tendon transfer 1% (17/1954) 5 Thompson test, debridement of osseous spur and primary repair 2% (41/1954) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A Type & Select Correct Answer 1 Equinus casting for 6 to 8 weeks 1% (47/4568) 2 Surgical repair through an percutaneous approach with plantaris transfer 1% (40/4568) 3 Surgical reconstruction through an open approach with Achilles allograft 18% (840/4568) 4 Surgical repair through an open approach with flexor hallucis longus transfer 78% (3564/4568) 5 Surgical repair through an limited open approach with peroneus longus transfer 1% (40/4568) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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 Type & Select Correct Answer 1 Improved ankle dorsiflexion strength at 6 month follow-up 3% (150/5397) 2 Improved ankle dorsiflexion range-of-motion at 6 month follow-up 2% (87/5397) 3 Improved mean SMFA scores at 12 months 1% (79/5397) 4 A statistically significant decrease in re-rupture rates 25% (1363/5397) 5 Increased complication rates 68% (3684/5397) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 1 1st digit proximal phalanx, Tibial nerve 12% (242/2067) 2 1st digit distal phalanx, Superficial peroneal nerve 3% (58/2067) 3 Base of the 5th metatarsal, Superficial peroneal nerve 4% (73/2067) 4 1st cuneiform and 1st metatarsal, Deep peroneal nerve 4% (76/2067) 5 1st digit distal phalanx, Tibial nerve 77% (1599/2067) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (SBQ12FA.20) What would be the most appropriate treatment for the sub-acute injury seen in Figures A-C? QID: 3827 FIGURES: A B C Type & Select Correct Answer 1 End-to-end repair 4% (172/4102) 2 Carbon fiber composites synthetic graft 1% (21/4102) 3 Achilles tendon xenograft with medial and lateral aponeurotic fascial turndown flaps 4% (181/4102) 4 Posterior tibialis tendon transfer with medial and lateral aponeurotic fascial turndown flaps 3% (129/4102) 5 Flexor hallucis longus tendon transfer with sliding V-Y advancement of the gastrocnemius-soleus complex aponeurosis 87% (3571/4102) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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: A B Type & Select Correct Answer 1 Weakness on resisted foot eversion 6% (176/2802) 2 Weakness on resisted hallux plantarflexion 79% (2211/2802) 3 Weakness on resisted hallux dorsiflexion 6% (164/2802) 4 Weakness on resisted ankle inversion 5% (151/2802) 5 Weakness on resisted ankle dorsiflexion 3% (82/2802) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A Type & Select Correct Answer 1 Primary repair of the re-ruptured Achilles tendon 1% (40/4768) 2 Debridement of necrotic and infected tendon tissue, with no attempt at reconstruction 77% (3686/4768) 3 V-Y plasty of the re-ruptured Achilles tendon 3% (153/4768) 4 Repair of the re-ruptured Achilles tendon with a turndown procedure 4% (173/4768) 5 Repair of defect with flexor hallucis longus tendon transfer 14% (678/4768) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 1 Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon 5% (168/3251) 2 Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus 3% (88/3251) 3 Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus 85% (2751/3251) 4 Reconstruction with hamstring autograft 6% (197/3251) 5 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1% (31/3251) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 1 Lower rate of infection 1% (20/3127) 2 Higher rate of normal skin sensation 1% (16/3127) 3 Better skin cosmesis 2% (48/3127) 4 Lower rate of dehiscence 1% (26/3127) 5 Lower rate of re-rupture 96% (3007/3127) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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 Type & Select Correct Answer 1 They have lower patient satisfaction scores 4% (91/2232) 2 They are less likely to return to sport 4% (89/2232) 3 Their ultimate strength is decreased 13% (280/2232) 4 They have a higher risk for rerupture 77% (1709/2232) 5 They have a higher risk of skin problems 3% (56/2232) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.270) Which factor increases the chance of wound complications after Achilles tendon repair? QID: 281 Type & Select Correct Answer 1 Increased body mass index 4% (90/2229) 2 Immediate surgery 1% (28/2229) 3 Male gender 1% (13/2229) 4 Age over 40 years old 1% (17/2229) 5 Tobacco use 93% (2075/2229) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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 the expected outcome seen with nonoperative management with early functional rehabilitation as compared with operative treatment? QID: 1241 Type & Select Correct Answer 1 Decreased incidence of deep venous thrombosis 7% (124/1846) 2 No significant difference in functional outcomes 51% (942/1846) 3 Increased rate of re-rupture 24% (448/1846) 4 Earlier return to sport 9% (171/1846) 5 Increased rate of complications 8% (148/1846) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (17) Podcasts (2) Orthopaedic Summit Evolving Techniques 2021 Feature Lecture: The Neglected Achilles Tendon Rupture: How To Bridge The Gap - Michael J. Coughlin, MD Foot & Ankle - Achilles Tendon Rupture 9/23/2022 327 views 5.0 (1) Orthopaedic Summit Evolving Techniques 2020 Pro: MIS: Less With Great New Devices Is More & Safe - Phinit Phisitkul, MD Phinit Phisitkul Foot & Ankle - Achilles Tendon Rupture 3/7/2022 591 views 4.0 (1) Login to View Community Videos Login to View Community Videos Orthopaedic Summit Evolving Techniques 2020 Pro: Traditional Open Repair Solves The Day Every Day - Richard Ferkel, MD Foot & Ankle - Achilles Tendon Rupture 3/7/2022 221 views 3.0 (1) Foot & Ankle ⎜Achilles Tendon Rupture Foot & Ankle - Achilles Tendon Rupture Listen Now 16:29 min 10/16/2019 973 plays 5.0 (5) Question Session⎜Achilles Tendon Rupture, Femoroacetabular Impingement & TKA in Patella Baja (Infera) Orthobullets Team Foot & Ankle - Achilles Tendon Rupture Listen Now 28:52 min 11/11/2019 119 plays 0.0 (0) See More See Less
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