achilles tendon rupture in the athlete: fix it, re-rupture, and

AOFAS Symposium 7– Sports: The Strong Finish Tuesday, September 23, 2014 1:30 – 3:15 pm

Moderator: Mark S. Myerson, MD Baltimore, Maryland

Achilles Tendon Rupture in the Athlete:

Fix It, Re-Rupture, and Return to Play

Martin J. O’Malley, MD Associate Professor of Orthopedic Surgery, Weill Cornell Medical College The Hospital for Special Surgery, NY, NY Medical Staff, The Brooklyn Nets Foot & Ankle Consultant, The New York Knicks New York, New York

Acute Achilles Tendon Rupture

* Introduction

Epidemiology: 18 per 100,000 per year—may be missed in up to 25% of patients

In men aged 30-40 years old, acute Achilles tendon ruptures are more common in episodic athletes (weekend warriors) than they are in professional athletes

Incidence in professional athletes is much lower than is the incidence in the general population: o NBA: 18 ruptures in 23 seasons (.078 ruptures per season)1 o NFL: 31 ruptures in 5 seasons (6.2 ruptures per season)10 o UEFA Champions League: 9 ruptures in 11 seasons (0.82 ruptures per season)3

*Mechanism

Usually traumatic during sports that involve explosive acceleration or maximal effort such as basketball, tennis, football and soccer

Rupture is often caused by violent forced dorsiflexion

Rupture occurs 4-6 cm above the insertion in a relatively hypovascular area

*Diagnosis

Patient often feels a “pop” or reports “someone kicked me” followed by difficulty walking with pain

© American Orthopaedic Foot & Ankle Society

Physical examination reveals a palpable gap, increased range of motion in dorsiflexion, and a positive Thompson test

*Imaging

For equivocal cases (partial rupture), use ultrasound as well as possible preoperative planning if the patient has a longstanding history of Achilles problems (MRI)

*Treatment

Optimal treatment for acute Achilles tendon ruptures is still a subject of debate. Studies examining surgical intervention report complications such as re-ruptures and wound complications without focusing on functional outcomes

Nonoperative treatment involves functional bracing and casting in equinus

Young, Patel, Zhu, et al. Weight-bearing in the Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Randomized Controlled Trial (J Bone Joint Surg Am 2014).

o There was no significant difference in re-rupture rate between patients in weight-bearing and non-weight-bearing casts18

o Patients in weight-bearing casts reported less subjective stiffness one-year postoperatively than did patients in non-weight-bearing casts, though both groups reported the same amount of pain and patient satisfaction

o There were no significant functional differences between those who wore weight-bearing casts and those who wore non-weight-bearing casts

Willits, Amendola, Bryant et al. – Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation (JBJS 2010)

o Accelerated functional rehab and nonoperative treatment was used for acute ruptures. All measured outcomes of nonoperative treatment were acceptable and advocated accelerated rehabilitation (walking boot with 2cm lift)17

o A closer look at the graph below reveals that there is a small but significant difference in plantarflecxion strength ratio at 240degrees per second (plyometrics, high speed contractility, fast twitch)


Olsson, Grävare Silbernagel, Eriksson – Stable Surgical Repair with Accelerated Rehabilitation Versus Nonsurgical Treatment for Acute Achilles Tendon Ruptures: A Randomized Controlled Study (AJSM 2013)

o From the article: “The results of the present study demonstrate that stable surgical repair with accelerated tendon loading could be performed in all patients without re-ruptures and major soft tissue–related complications. However, this treatment was not significantly superior to nonsurgical treatment in terms of functional results, physical activity, or quality of life.”8

o A closer look shows a trend toward superior functionality in the surgical group; the results were significantly superior when assessed by the drop counterjump movement and during hopping

o There were no re-ruptures in the surgical group and five re-ruptures in the nonsurgical group

*CONCLUSION: For most patients, nonoperative treatment outcomes are comparable to operative treatment outcomes. These patients are at a slightly higher risk of re-rupture, but they are likely to have fewer complications compared to those who are treated surgically. However, operative treatment offers significant functional improvements during high-speed activities and hopping. Therefore, operative treatment is recommended in athletes.

*Operative Treatment

Open, percutaneous, mini-incision (Achillion, PARS). The goal is to set muscle tendon unit tension equal to opposite side and start rehabilitation early

o Personal choice: No. 2 fiber wire, modified Bunnell with running epitendinous cross stitch of 2.0 vicryl, keep knots inside tendon, close paratenon

Operative treatment is associated with higher complication rates in most studies (except Olsson, Grävare Silbernagel, Eriksson (AJSM 2013))8

Ideal for athletes because plantar flexion strength at high velocity, hopping, and counter jump movements are all significantly better than is strength in patients who received nonoperative treatment


*Re-Rupture

More common following nonoperative treatment

Rettig, Liotta, Klootwyk, Porter, Mieling. Potential Risk of Rerupture in Primary Achilles Tendon Repair in Athletes Younger than 30 Years of Age (Am J Sports Med 2005)

o Risk of re-rupture is higher in younger patients with accelerated postoperative protocol (<30 yrs old = 16.6% rate, >30 yrs old = 0% rate). Re-rupture at average of seven weeks postoperatively. All patients were treated with revision of primary repair, and all returned to sports12

*Options for Re-Rupture

Re-Repair Primarily o If this procedure is chosen, then slower rehabilitation will likely follow. Slower

rehabilitation has been shown to have inferior results compared to accelerated rehabilitation

o Unless the re-rupture occurs as a result of trauma, we have to assume that re-rupture occurs due to degenerative tendon, and I would recommend some type of augmentation

Repair Plus Turn-Down or V-Y Plasty o Nilsson-Helander, Sward, Silbernagel, et al. A New Surgical Method to Treat Chronic

Ruptures and Re-ruptures of the Achilles Tendon (Knee Surg Sports Traumatol Arthrosc 2008)

Free the gastrocnemius aponeurosis flap to cover the gap after end to end suture7

These ruptures healed, but there were significant decreases in strength and toe-raise test for endurance in patients who underwent this procedure

Local Tendon Transfer (FHL, FDL, Peroneal Tendon) o Mutliple reports show adequate results but most studies focused on chronic Achilles

tendonosis instead of tendon rupture o The patients undergoing this procedure are older than are patients receiving other

procedures, but many studies have shown significant FHL weakness, decreased IP pressure, and notable Achilles tendon weakness (75% compared to opposite side)

Therefore, the above procedure would be cautioned against with athletic patients

o FDL may be a better choice because of less donor site morbidity, but the transfer is technically more difficult because the tendon must be transferred around a neurovascular bundle bundle10,12,15

Distant Autograft (Hamstring) o Chronic tear patients were able to walk on their toes, but at follow-up, their treated legs

were substantially weaker and maximal calf circumferences were substantially decreased6

o This procedure is a good option for acute re-rupture as it adds enough strength for resumption of early mobilization


Allograft o Achilles allograft is used extensively for extensor mechanism of the knee o There are no large case series regarding Achilles repair, only case reports o Wound complications might be cause for concern

*SUMMARY

There is strong level 1 evidence for nonoperative treatment of Achilles ruptures as long as accelerated rehabilitation and early weightbearing are performed in most patients

o However, nonoperative treatment leads to statistically significant deficits in high speed plantar flexion strength and hopping ability, which is crucial for professional athletes

Re-rupture rate is higher in nonoperative treatment, but nonoperative treatment leads to fewer complications

Re-ruptures repaired primarily seem to do well as long as they do not get infected, but the number of patients who have received this procedure is still low

Mini-incision surgery may minimize wound complications, but these repairs tend to be weaker than are open repairs

Whether operative or nonoperative treatment is chosen, early weight bearing and rehabilitation are paramount to good functional outcomes

Bibliography

1. Amin NH, Old AB, Tabb LP, Garg R, Toossi N, Cerynik DL. Performance outcomes after repair of complete Achilles tendon ruptures in National Basketball Association players. Am J Sports Med. 2013;41:1864-1868.

2. Chan JY, Elliott AJ, Ellis SJ. Reconstruction of Achilles rerupture with peroneus longus tendon transfer. Foot Ankle Int. 2013;34:898-903.

3. Gajhede-Knudsen M, Ekstrand J, Magnusson H, Maffulli N. Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: An 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med. 2013;47:763-768.

4. Jones MP, Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon rupture: Key findings from a recent Cochrane review. J Bone Joint Surg Am. 2012;94:e88.

5. Keating JF, Will EM. Operative versus non-operative treatment of acute rupture of tendo Achillis: A prospective randomised evaluation of functional outcome. J Bone Joint Surg Br. 2011;93(8):1071-1078.

6. Maffulli N, Spiezia F, Testa V, Capasso G, Longo UG, Denaro V. Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon. J Bone Joint Surg Am. 2012;94:906-910.

7. Nilsson-Helander K, Sward L, Silbernagel KG, et al. A new surgical method to treat chronic ruptures and reruptures of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc. 2008;16(6):614-620.

8. Olsson N, Grävare Silbernagel K, Eriksson, BI. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: A randomized controlled study. Am J Sports Med. 2013;41:2867-2876.


9. Pajala A, Kangas J, Ohtonen P, Leppilahti J. Rerupture and deep infection following treatment of total Achilles tendon rupture. J Bone Joint Surg Am. 2002; 84:2016-2021.

10. Parekh SG, Wray WH, Brimmo O, Sennett BJ, Wapner KL. Epidemiology and outcomes of Achilles tendon ruptures in the National Football League. Foot Ankle Spec. 2009;2:283-286.

11. Rahm S, Spross C, Gerber F, Farshad M, Buck FM, Espinosa N. Operative treatment of chronic irreparable Achilles tendon ruptures with large flexor hallucis longus tendon transfers. Foot Ankle Int. 2013;34:1100-1110.

12. Rettig AC, Liotta FJ, Klootwyk TE, Porter DA. Mieling P. Potential risk of rerupture in primary Achilles tendon repair in athletes younger than 30 years of age. Am J Sports Med. 2005;33:119-123.

13. Richardson DR, Willers J, Cohen BE, Davis WH, Jones CP, Anderson RB. Evaluation of the hallux morbidity of single-incision flexor hallucis longus tendon transfer. Foot Ankle Int. 2009;3-:627-630.

14. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: A meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94:2136–2143.

15. van der Eng DM, Schepers T, Goslings JC, Schep NWL. Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: A meta-analysis. J Foot Ankle Surg. 2013; 52:622-628.

16. Will RE, Galey SM. Outcome of single incision flexor hallucis longus transfer for chronic Achilles tendinopathy. Foot Ankle Int. 2009;30:315-317.

17. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: A multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92:2767-2775.

18. Young SW, Patel A, Zhu M, et al. Weight-bearing in the nonoperative treatment of acute Achilles tendon ruptures: A randomized controlled trial. J Bone Joint Surg Am. 2014;96:1073-1079.


achilles tendon rupture in the athlete: fix it, re-rupture, and

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