acute achilles tendon rupture paul herickhoff, md march 26, 2009
TRANSCRIPT
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Acute Achilles Tendon Rupture
Paul Herickhoff, MD
March 26, 2009
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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
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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
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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
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Diagnosis
• Weakness in plantarflexion
• Gap in tendon
• Positive Thompson test
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Imaging
• X-rays– Indicated if fracture or
avulsion fracture suspected
• Ultrasound or MRI– Reveal tendon
degeneration, if present
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Treatment
• Non-operative versus operative treatment controversial– Several methods
described for each
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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
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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%)
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Operative
• Percutaneous– Bunnell stitch– Weaker than open
repair (Rerupture 0-17%)
– Risk of sural nerve injury (0-13%)
– Decreased infection risk
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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
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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%)
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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)
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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
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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.